CQC report explained · a nursing home
What the CQC found at Rock Cottage Care Services
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People's risks were identified and managed, but some risk assessments and care plans were incomplete, missing or contradictory. Not all permanent staff had completed required training.
- Effective?
- Requires improvement
- This question was not inspected during this focused inspection. Its previous rating was carried forward, but that rating is not stated in this report.
- Caring?
- Good
- This question was not inspected during this focused inspection. Its previous rating was carried forward, but that rating is not stated in this report.
- Responsive?
- Good
- This question was not inspected during this focused inspection. Its previous rating was carried forward, but that rating is not stated in this report.
- Well-led?
- Requires improvement
- Management roles were not clearly shared, and auditing did not always identify or correct problems. The provider's governance systems were not robust enough to give clear oversight.
What inspectors found, January 2024
Rock Cottage Care Services is rated Requires Improvement; inspectors found caring support but gaps in risk records, staff training and management checks.
This was an unannounced focused inspection on 13 and 15 November 2023. Inspectors spoke with people, relatives and staff, and checked care records, medicines records, staff files, audits and other documents.
The home had enough staff, and people were supported with medicines and infection control. However, some risks were not clearly assessed or recorded. Not all permanent staff had completed required training, including training for specific needs.
The home was not always well managed. Checks did not consistently lead to improvements, lessons from incidents were not clearly shared, and management responsibilities were not fully clear. The overall rating changed from Good at the last inspection to Requires Improvement.
Enough staff
Inspectors found there were enough staff to meet people's needs, although the home relied on agency workers and some staff lacked required training.
“Whilst we found there were enough staff to support people and meet their needs” from the report
Medicines support
Staff had medicines training and competency checks. People's records included guidance, and people said they received medicines safely.
“People were supported to receive their medicines safely.” from the report
Infection control
Staff followed safe infection prevention and control practices and completed cleaning schedules. Some refurbishment and carpet replacement was under way.
“People were protected from the risk of infection as staff were following safe infection prevention and control practices.” from the report
Positive culture
People and relatives described a caring and homely atmosphere. Staff said managers were approachable, and the home had an open-door approach to concerns.
“There was a positive and open culture at the service.” from the report
Incomplete risk guidance
seriousSome risks did not have clear assessments or instructions for staff. This included catheter care and transferring one person from bed to chair, which could lead to harm.
“This placed the person at risk of possible injury.” from the report
Required training incomplete
needs fixingNot all permanent staff had completed essential training or training for specific needs, including diabetes and catheter care.
“This included mandatory [essential] training and training for people with specific needs, for example diabetes or catheter care.” from the report
Incidents not used to learn
seriousThe provider took action after accidents and incidents, but did not analyse their causes or clearly share lessons with staff to reduce the chance of recurrence.
“There was not an established system in place to provide feedback and learn lessons when things went wrong.” from the report
Weak management checks
seriousAudits did not always lead to action. Problems with care records and medicines records were identified but were not consistently followed up.
“The auditing and monitoring systems in place were not robust enough for clear oversight of the service to make improvements.” from the report
Agency staff familiarity
minorPeople and staff said agency workers did not always know people as well as permanent staff and could sometimes find communication difficult.
“agency workers sometimes struggle to communicate, and it is hard to get my point over.” from the report
- 01What action has been completed to make risk assessments and care plans accurate, complete and consistent?
- 02Which permanent staff have now completed training for diabetes, catheter care and other people's specific needs?
- 03How do you record and share lessons after accidents, incidents or injuries?
- 04How are management roles divided now, and how do you check that identified problems are corrected?
- 05How do you make sure agency staff understand each person's needs and can communicate effectively with them?
This was a focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection and were not stated in this report. This explanation was written from the published report of 6 January 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, January 2022
Rated Good; inspectors found safe, kind and personalised care, but staffing levels and formal feedback needed attention.
This was an unannounced focused inspection on 13 December 2021. Inspectors spoke with five people, 11 relatives and seven staff. They reviewed care records, medicine records, recruitment and management documents.
The home was rated Good for Safe, Caring, Responsive and Well-led. Inspectors found people were protected from harm, treated with dignity and supported with personalised care. Medicines and infection control were managed safely.
Some people and staff said there were not always enough staff and people could be left waiting. Inspectors did not see this during the visit and found no evidence of harm, but recommended checking dependency levels against staffing. People also said they did not always have formal ways to give feedback.
The previous rating was Requires Improvement, published in September 2020, with a breach of Regulation 17. The report says improvements had been made and the home was no longer in breach. Effective was not inspected, so its previous rating was used in the overall result.
Safe medicines
The electronic medicines system had been embedded since the previous inspection. Inspectors found medicines were given safely and records matched stock checks.
“There was an electronic medicines management system in place. This had been fully embedded since our last inspection and had reduced the margin for medication errors to occur.” from the report
Kind and respectful care
People described staff as kind and caring. Inspectors saw staff protecting people's privacy and dignity during personal care and meals.
“Overall, people told us they were well supported by kind, compassionate and caring staff.” from the report
Personalised support
Care plans included people's needs, wishes and communication requirements. The home also provided additional communication support where needed.
“Care plans were person centred and took into consideration people's needs and wishes.” from the report
Improved management checks
The home had introduced regular audits and acted on identified shortfalls. This addressed the previous governance breach.
“Since our last inspection, the registered manager had implemented an effective system to assess and monitor the quality and safety of the service.” from the report
Staffing levels
needs fixingSome people and staff felt there were not enough staff at times and that people could be left waiting. Inspectors did not observe this and found no evidence of harm, but recommended a review of dependency scores.
“Some people and staff told us they did not feel there were enough staff across the service and told us sometimes people were left waiting to receive support.” from the report
Formal feedback
minorPeople said they did not always have formal ways to share their views about the service. The manager said they would develop new ways for everyone to take part.
“People told us they did not always get the opportunity to feedback about the service through formal mechanisms such as surveys and questionnaires.” from the report
Range of activities
minorAn activities programme was in place, but some people said they wanted more activities. Inspectors raised this with the activity coordinator.
“People gave us their views about activities and told us they would like to have other activities available to them.” from the report
- 01How have you reviewed people's dependency scores, and how do these scores now determine staffing levels?
- 02What arrangements were made for the move to the new registered manager, and who is currently responsible for day-to-day management?
- 03What formal ways can residents and relatives now use to give feedback about the service?
- 04What additional activities have been introduced in response to residents asking for more choice?
This was a focused inspection of Safe, Caring, Responsive and Well-led; Effective was not inspected and its previous rating was carried over. This explanation was written from the published report of 12 January 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Rock Cottage Care Services
6 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- January 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2022Goodup from Requires improvementSafe: GoodWell-led: Good
- October 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2019Requires improvementstayed Requires improvementSafe: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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