CQC report explained · a nursing home
What the CQC found at Rose Cottage Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Records did not always show that bruising, safeguarding concerns and other risks had been investigated or acted on. Medicines records and some risk assessments were incomplete, although inspectors found enough staff and good infection control arrangements.
- Effective?
- Requires improvement
- Care plans were person-centred and people received support with food, drink and healthcare. However, some staff training was incomplete and best-interest decision records did not always include the required professional involvement.
- Caring?
- Good
- This question was not inspected during this focused visit. People and relatives gave positive feedback about staff and the care they received.
- Responsive?
- Good
- This question was not inspected during this focused visit. The report says people and relatives were involved in care planning and kept updated through newsletters, emails, calls and meetings.
- Well-led?
- Requires improvement
- The home had audits and management systems, but they failed to identify several concerns about medicines, records, training, equipment and incidents. Communication about incidents and responsibility for some parts of the service were not always clear.
What inspectors found, April 2023
Rated Requires Improvement; inspectors found risks in safeguarding, medicines, records, training and quality checks.
This was an unannounced focused inspection on 1 December 2022. Inspectors reviewed Safe, Effective and Well-led. They spoke with people, relatives and staff, observed care, and checked care records, medicines records, staff files, incidents and audits.
The home was not always able to show that people were protected from harm. Safeguarding records, risk assessments, medicines records and incident investigations were incomplete or not always followed up. Some staff training was also overdue or incomplete.
There were positive findings. Inspectors saw enough staff, kind support at mealtimes, person-centred care plans and appropriate contact with health professionals. People and relatives generally said they felt safe and were happy with the care.
The overall rating changed from Good at the previous inspection in January 2019 to Requires Improvement. Safe, Effective and Well-led were all rated Requires Improvement. Caring and Responsive were not inspected in this visit, so their previous ratings were used for the overall rating.
Staffing
Inspectors found enough staff to meet people's needs. Staff said they had enough time, skills and support.
“There were enough staff to meet people's needs. Staff told us they felt they had the skills, time and support they needed to meet people's needs.” from the report
Food and mealtimes
People were offered choices and alternatives. Staff knew people's diets and preferences and supported people to eat in a kind way.
“During the inspection, we observed lunch which was efficient and timely. We saw people being offered choice and alternatives, and staff knew people's diets and preferences.” from the report
Person-centred care
Care plans reflected people's needs and were reviewed frequently. People and relatives said they were involved in care planning.
“People's care plans were person centred. Person centred assessments were carried out on admission.” from the report
Healthcare support
The home worked with a range of health and social care professionals. Changes recommended by professionals were recorded and put into practice.
“We saw that the service communicated with other services and professionals in order to support people to live healthier lives” from the report
Safeguarding records
seriousRecords did not always show what action had been taken after bruising or other concerns. Some incidents were not recorded as safeguarding matters or shared clearly with staff.
“Records did not always demonstrate that the registered manager understood their responsibility to report any evidence of abuse promptly.” from the report
Medicines management
seriousSome medicine records were incomplete, controlled medicine checks had not always been done and thickening agents were left in an unlocked drawer. CQC said this placed people at risk of harm.
“The lack of system in place to ensure that medicines were managed safely placed people at risk of harm.” from the report
Risk and incident follow-up
seriousSome risk assessments were not reviewed as required. The home did not consistently investigate incidents, record lessons or share actions to prevent problems happening again.
“Lessons learnt documents were not completed following an incident and incidents were not always shared by management with the whole team.” from the report
Staff training
needs fixingSome staff had not completed training in areas including dementia, first aid, risk assessment, epilepsy and falls prevention. Inspectors linked recent safeguarding concerns to gaps in staff knowledge.
“Some staff had not completed training in dementia awareness training, first aid, oral healthcare, risk assessment, fire safety, deprivation of liberty, epilepsy and falls prevention.” from the report
Quality monitoring
seriousAudits were in place but did not identify important problems found by inspectors. This included concerns about medicines, records, feedback, training and equipment.
“Systems and processes to monitor and improve the quality and safety of the service were ineffective” from the report
- 01What has changed since the inspection to make sure bruising, safeguarding concerns and incidents are investigated and recorded?
- 02How are controlled medicines now checked, and how are all medicines records reviewed for gaps?
- 03Which staff still need training in dementia, epilepsy, falls prevention, first aid and risk assessment?
- 04How are risk assessments reviewed on time, especially for people at risk of pressure damage?
- 05How will you show families that audits identify problems and that lessons from incidents are shared with all staff?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were used in the overall rating. This explanation was written from the published report of 6 April 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.
What inspectors found, March 2022
Rose Cottage Nursing Home was inspected but not rated; inspectors found good infection control overall, with one visitor safety issue fixed immediately.
This was an unannounced, targeted inspection on 3 March 2022. It focused on infection prevention and control, visiting arrangements and the effect of COVID-19 staffing pressures.
Inspectors found the home clean, tidy and fresh-smelling. They were assured about testing, protective equipment, admissions, social distancing, outbreak planning and the infection control policy.
There was one issue during the visit. Maintenance contractors were not wearing protective equipment. This was raised with the manager and actioned immediately. The home was inspected but not rated, so this report does not give an overall quality rating.
Clean environment
The home was clean and hygienic, supported by regular cleaning schedules.
“The home was clean, tidy and smelled fresh. Rigorous cleaning schedules ensured the home was maintained to a safe and hygienic standard.” from the report
Infection control
Inspectors were assured that the home had arrangements to reduce and manage infection risks, including testing and protective equipment.
“We were assured the service were following safe infection prevention and control procedures to keep people safe.” from the report
Outbreak planning
The management team had a detailed plan and risk assessments for dealing with a COVID-19 outbreak.
“There was a comprehensive contingency plan of what to do in case of an outbreak.” from the report
Visiting arrangements
The home checked visitors and followed the government requirements described in the report for visits and vaccination.
“The provider was ensuring they were following the latest government guidance in relation to people continuing to have visits with their relatives.” from the report
Contractors lacked protective equipment
needs fixingInspectors saw maintenance contractors working without protective equipment. The issue was raised with the manager and actioned immediately.
“We observed that maintenance contractors were not wearing PPE whilst working on site.” from the report
- 01How do you now make sure maintenance contractors wear protective equipment while working in the home?
- 02How are visitors currently checked, including testing, vaccination and temperature checks?
- 03How do you manage staffing pressures linked to COVID-19, and what effect do they have on people living here?
- 04How often are people and staff tested for infections now?
- 05Can you show us the current outbreak contingency plan and explain how it would be used?
This was an unannounced targeted inspection of infection prevention and control, visiting arrangements and COVID-19 staffing pressures; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 18 March 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 Rose Cottage Nursing Home
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- April 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2022Inspected but not ratedSafe: Inspected but not rated
- January 2019Goodstayed GoodSafe: GoodEffective: GoodWell-led: Requires improvement
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- June 2011
Registered with the Care Quality Commission on 9 June 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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