CQC report explained · a nursing home
What the CQC found at Rose Lodge Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2024
Summerfield House Nursing Home was rated Inadequate and placed in special measures because inspectors found serious risks in safety and management.
This was an unannounced focused inspection. Inspectors visited on 16, 24, 25 January, and 5 and 8 February 2024. They observed care, spoke with people, relatives, staff and professionals, and checked care, medicine, recruitment and management records.
The home was not always safe. Risks were not managed properly, medicines records were unreliable, staffing was not always sufficient, training was out of date and recruitment checks were incomplete. People were not always treated with dignity, and care was not consistently person-centred.
The home was rated Inadequate overall, for Safe and for Well-led. Caring was rated Requires Improvement. The ratings for Effective and Responsive were not assessed during this inspection and were carried forward from the previous inspection. The provider made an action plan, increased staffing and brought in extra senior management, but CQC said it would check progress at a future inspection.
Clean environment
The environment was clean and well maintained. Inspectors found good infection control practices and appropriate use of protective equipment.
“Good standards of hygiene and cleanliness were maintained. Staff wore PPE appropriately.” from the report
Visiting
People could receive visitors without restrictions. Relatives said they could visit at any time.
“People were supported to keep in touch with friends and relatives.” from the report
Healthcare links
People had access to healthcare services, and care records showed involvement from health and social care professionals.
“Care records showed the involvement of health and social care professionals in people's care.” from the report
Unsafe medicines
seriousMedicine records were incomplete or inaccurate. This included medicines for swallowing difficulties, as-needed medicines, hidden medicines and medicine patches.
“We found medicines were not managed safely. This was a breach of regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Risks not managed
seriousInspectors found problems with pressure-relieving equipment, specialist diets, weight loss, fire drills and recording incidents. Risks to people and staff were not always reviewed properly.
“Risks to people were not always assessed and managed placing them at risk of harm.” from the report
Insufficient staffing
seriousPeople sometimes waited too long for help, and inspectors had to ask staff to assist people. Staff deployment and safety training were also not always adequate.
“We found there were not always sufficient staff deployed to meet people's needs and keep them safe.” from the report
Dignity and communication
seriousSome staff did not explain care, respond to distress or protect privacy. Inspectors saw people exposed while using the toilet and heard people referred to by room numbers.
“People were not always treated with dignity and respect. This was a breach of regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Safeguarding concerns
seriousInspectors identified concerns about care practices that the management team had not found. One person was restricted to staying in bed because a specialist chair had to be shared.
“People were not protected from abuse and improper treatment. This was a breach of regulation 13(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Weak oversight
seriousThe provider's checks did not identify or resolve repeated problems. Incident analysis, handovers and care records were not consistently accurate or useful.
“The provider's systems and processes were not established or operated effectively to assess and monitor the service, and to ensure continuous learning and the improvement of the quality of care.” from the report
- 01What has changed in the medicines system, and how are you checking that thickening powder, as-needed and hidden medicines are recorded and given safely?
- 02How many staff are now scheduled on each floor and at night, and how do you check that people respond promptly to call bells and requests for help?
- 03What action has been taken to protect people from abuse, distress and loss of dignity, including privacy when using the toilet or taking phone calls?
- 04How are risks such as pressure damage, choking, weight loss and fire safety now assessed, recorded and reviewed?
- 05Who is currently leading the home, and how will you show that the action plan is working and that concerns raised by residents and relatives are acted on?
This was a focused inspection of Safe, Caring and Well-led only; Effective and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 6 April 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, November 2023
Rated Requires Improvement; inspectors found kind care and improved management, but risk records and some personalised support were not reliable.
Inspectors visited on 26 and 28 September and 2 October 2023. They spoke with people, relatives, staff and visiting professionals. They reviewed care plans, medicines records, incident reports and management systems, and observed care.
The home had improved since a new manager started. Staff were kind and respectful. Medicines were given safely, people's health needs were generally supported, and feedback from families and professionals was positive.
However, risks were not always assessed or managed properly. Some accidents, bruising and behaviour incidents were not recorded correctly. Care plans did not always give clear, personal guidance. There were also limited activities and some problems with recording food intake.
The overall rating remains Requires Improvement. Safe, Effective, Responsive and Well-led were rated Requires Improvement. Caring was rated Good. This was the home's fifth consecutive Requires Improvement rating.
Kind and respectful staff
People and relatives were positive about the staff. Inspectors saw many caring interactions and found that people were treated with dignity.
“We observed many lovely, caring interactions between people and members of staff.” from the report
Medicines were safer
People received medicines as prescribed, including time-critical medicines. Audits and checks had improved medicines management.
“People received their medicines as prescribed. All the medicines people needed were available in the home.” from the report
Management improvements
A new manager had introduced an improvement plan, regular audits and clearer staff roles. Staff and professionals said the home was moving in the right direction.
“It was clear that improvements had been made since the new manager had joined the service.” from the report
Health support
People's health needs were being met. The home worked with GPs and other professionals, and referrals were made when needed.
“People's health needs were being met. The GP had a weekly consultation with the home to quickly support any person who was starting to feel unwell.” from the report
Risk information was not reliable
seriousSome changed risks, falls and behaviour incidents were not properly assessed or recorded. This meant staff did not always have the right guidance and incidents could not always be reviewed.
“However, we saw examples where risk was not consistently assessed and managed.” from the report
Care plans lacked personal detail
needs fixingSome care plans did not explain clearly how to meet an individual's needs. Information was sometimes generic or split across different sections.
“We found some care plans did not contain all the relevant information to provide clear guidance to staff.” from the report
Limited activities
needs fixingInspectors saw very few activities and little stimulation. The home was recruiting more activity workers and planning a fuller programme.
“We saw very limited activities and stimulation for people living at the home.” from the report
End of life plans were too general
needs fixingSome end of life plans did not reflect the person's wishes and used general statements rather than personal information.
“People had end of life plans, but these did not always reflect their wishes.” from the report
Staff could be too busy
minorStaff were able to respond to people's needs, but inspectors saw them busy and task focused. Some staff said they felt rushed and needed more time.
“Staff were seen to be busy but were able to respond to people's needs.” from the report
- 01How do you now record and review falls, bruising and behaviour incidents?
- 02How will you make sure care plans give clear, individual guidance about risks, wounds and pressure relief?
- 03What staffing levels and staff allocations are in place at busy times, across all three floors?
- 04What activities are now available each day, and how do you tailor them to each person's interests?
- 05How have end of life plans been updated to record each person's wishes?
This was a comprehensive inspection covering all five key questions, including infection prevention and control, and was prompted partly by concerns about management, staffing, medicines and falls. This explanation was written from the published report of 10 November 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 Rose Lodge Care Home
7 rated inspections over 7 years: the service has slipped, from Good to Inadequate.
- April 2024Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- November 2023Requires improvementstayed Requires improvementSafe: Requires improvementCaring: GoodWell-led: Requires improvement
- April 2023Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- July 2022Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- September 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Good
- March 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016
Registered with the Care Quality Commission on 27 May 2016.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Calderdale
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 87 can care for a couple. 12 years' experience on average.
“Primrose is a very kind and compassionate healthcare professional”
“Carla has been a god send with the implementation of bringing mum back home from respite care.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.