CQC report explained · a residential care home
What the CQC found at Roop Cottage Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, March 2024
Rated Inadequate and placed in special measures; inspectors found widespread risks, poor care planning and weak leadership.
The inspection was unannounced and took place over two days. Inspectors spoke with people living in the home, relatives, staff and a visiting professional. They reviewed care records, medicines records and management records.
The home was rated Inadequate in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found risks were not properly assessed, medicines systems were unsafe, staff training was not sufficient, and people's privacy, dignity, choices and daily routines were not consistently respected.
Some staff had kind and caring relationships with people. People and relatives also spoke positively about the food. However, many serious concerns had been raised before and the provider had not made enough improvement. The overall rating fell from Requires Improvement at the previous inspection.
Kind relationships
Some staff knew people well and had caring relationships with them and their families. Staff were described as kind and patient when providing care.
“Staff spoke with people in kind and caring ways. Some staff knew some of the people well and had established caring relationships with them and their families.” from the report
Food was enjoyed
People and relatives said the food was good, and people were shown visual choices of the food available. However, support with the timing and safety of eating and drinking was not reliable.
“The food is nice and you get plenty” from the report
Unmanaged safety risks
seriousPeople's risks were not fully assessed or followed up. Call bells were missing or out of reach, weight loss was not consistently acted on, and hazards in the building remained unresolved.
“Risks to people were not sufficiently assessed, monitored or mitigated.” from the report
Unsafe medicines systems
seriousMedicines records and staff guidance were not reliable. Some records lacked photographs, some guidance for as-needed medicines was missing or unclear, and nutritional supplements were not always given as prescribed.
“Systems and processes were not in place to ensure the safe management of medicines.” from the report
Insufficient staff training
needs fixingStaff had not been trained to meet several people's needs, including autism, learning disabilities, nutrition and hydration, oral health and dementia.
“Staff were not trained to support people with autism or a learning disability.” from the report
Dignity and privacy
seriousInspectors found poor support with personal care and oral hygiene. One person's privacy was not protected, and people's independence and choices were not consistently encouraged.
“People's dignity and respect was not promoted.” from the report
Care was not personalised
needs fixingMealtimes, personal care and daily routines were organised around staff availability. Some people remained in their rooms despite records showing they wanted to spend time elsewhere, and there were few meaningful activities.
“Care was not planned around people's individual needs, interests and preferences.” from the report
Weak leadership and follow-through
seriousManagers had changed, responsibilities were unclear and there was no registered manager. Previous concerns and promised improvements had not been effectively dealt with.
“There was a lack of accountability, understanding of risks and oversight.” from the report
- 01What immediate action has been taken to make sure call bells are available, working and within each person's reach?
- 02How are you now checking medicines records, as-needed medicines guidance and nutritional supplements?
- 03What changes have been made to ensure people receive drinks and meals at times that suit them and that choking, diabetes, weight loss and dehydration risks are managed?
- 04Which staff have now completed training for learning disabilities, autism, dementia, nutrition and hydration, oral health and end of life care?
- 05Who is currently accountable for the home, and what evidence can you show that the improvement plan is working?
The inspection was prompted by concerns about safety, nutrition, personal care, privacy, dignity and the environment, then widened to cover all five key questions. This explanation was written from the published report of 8 March 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, August 2023
Rated Requires Improvement, with inadequate leadership and serious concerns about medicines, risk management, staffing and cleanliness.
Inspectors visited unannounced on 26 April and 5 May 2023. They spoke with people living in the home, relatives and staff, and checked care records, medicines, staff files and management records.
The home was not always safe. Medicines records and storage were poor, some risks were not properly assessed, infection control was not effective, and recruitment and staff training checks were incomplete. Inspectors also found gaps in records about people's care, food and fluids.
Staff were generally kind and supported people's family relationships and community activities. However, care plans were not always detailed, some people had limited choices, and people did not always receive enough support with eating and drinking.
The overall rating remains Requires Improvement. Safe and Effective were rated Requires Improvement, while Well-led was rated Inadequate. The report says the home had not maintained the improvements identified after the previous inspection.
Kind staff
Staff were generally kind and patient in their interactions with people. Inspectors saw caring and sensitive communication.
“Staff were kind and patient and said they supported people in the least restrictive way possible and in their best interests.” from the report
Family contact
People were supported to keep in touch with family and friends. Visitors were allowed to visit at any time.
“Visitors were welcomed at any time into the home, and people had visits with family and friends.” from the report
Community activities
Staff helped people attend activities locally, including supporting one person to attend a local day centre.
“One person was supported to visit a local day centre to support their social and emotional needs.” from the report
Mental capacity practice
Inspectors found the home was working within the principles of the Mental Capacity Act, with appropriate legal authorisations where needed.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.” from the report
Medicines were not managed safely
seriousMedicines were stored and recorded poorly. There were gaps in records, incomplete guidance for some medicines, and inconsistent recording of creams and controlled drugs.
“Medicines were not managed safely. Storage and recording were poor.” from the report
Risks were not consistently controlled
seriousRisk assessments lacked detail and were not always followed. One person who needed supervision while eating was left alone on two occasions, and weight monitoring was not maintained.
“One person needed a soft consistency diet and to be supervised when eating, however, they were left alone on 2 occasions and once with a bowl of chewy sweets.” from the report
Infection control and cleanliness
seriousSome equipment and bathroom areas needed cleaning. Inspectors also found poor storage of personal items, stained carpets and bad odours.
“Systems were not effectively implemented to assess, prevent and control the spread of infections, and although there was no evidence people had been harmed, this placed them at risk of harm.” from the report
Staff checks and training
seriousRecruitment checks, induction, training, supervision and competency checks were not consistently completed. Some night staff were not trained to support people with medicines.
“The provider had failed to ensure staff had the appropriate support, training, professional development and supervision for their role.” from the report
Weak management oversight
seriousThere was no registered manager, responsibilities were unclear, and audits did not reliably identify or correct problems. Poor record keeping had continued from the previous inspection.
“The provider had failed to ensure systems and processes were established and operated effectively to assess, monitor and improve the safety of the service.” from the report
Food and drink records
needs fixingInspectors found limited evidence of drinks being offered, delays with meals and food that was not always the right consistency. Food and fluid records did not reliably show whether people's needs were met.
“Record keeping, such as food and fluid recording was not maintained sufficiently, and did not enable concerns to people's health to be identified or actioned.” from the report
- 01How are medicines now stored, recorded and checked, including creams, controlled drugs and 'as required' medicines?
- 02How do you make sure people at risk of choking, weight loss or malnutrition receive the right supervision, diet, drinks and monitoring?
- 03Which recruitment, induction, training and competency checks have been completed for the staff who would care for my relative?
- 04Who is currently responsible for managing the home, and how are risks, accidents, incidents and audit actions checked and followed up?
- 05What cleaning, maintenance and safety work has been completed since the inspection, including bathroom cleaning, hot water checks and the passenger lift?
This was an unannounced inspection covering Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried over when calculating the overall rating. This explanation was written from the published report of 11 August 2023 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 Roop Cottage Residential Home
7 rated inspections over 8 years: the service has slipped, from Requires improvement to Inadequate.
- March 2024Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
Read what inspectors found at Roop Cottage Residential Home →
- August 2023Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Inadequate
Read what inspectors found at Roop Cottage Residential Home →
- October 2022Requires improvementup from InadequateSafe: GoodWell-led: Requires improvement
- March 2022Inadequatestayed InadequateSafe: InadequateWell-led: Inadequate
- November 2021InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- February 2021Inspected but not ratedSafe: Inspected but not rated
- August 2017Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2021
Registered with the Care Quality Commission on 30 June 2021.
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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