CQC report explained · a residential care home
What the CQC found at Rose Meadow
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, August 2019
Rated Good overall, but well-led Requires Improvement because inspectors needed longer-term evidence that improvements would continue.
Inspectors made an unannounced follow-up visit on 3 June 2019. They spoke with three people, one relative, three staff and the manager. They also reviewed five people's care and medicine records, along with management records.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found major improvements since the previous inspection. Risks, medicines, staffing, care planning, staff training and the environment were managed more safely.
Well-led was rated Requires Improvement. The home had introduced better management systems and audits, but these were still new. Inspectors wanted to see that the improvements continued over a longer period.
The previous inspection had rated the home Inadequate and placed it in Special Measures. The home was no longer Inadequate or in Special Measures after this inspection.
Improved safety
Care plans, incident reviews, environmental checks and staffing arrangements had improved. Staff had better guidance on how to keep people safe.
“New processes meant people were safe and protected from avoidable harm.” from the report
Safer medicines
People received medicines as prescribed, storage was appropriate and staff had clear, individual guidance. Regular audits were used to identify problems.
“People received medicine as prescribed, medicine was stored appropriately and there was clear person-centred guidance in place for staff to follow.” from the report
Kind and respectful care
Inspectors observed positive interactions. Staff understood people's communication and supported privacy, dignity and independence.
“We observed positive interactions between staff and people.” from the report
Personalised support
People were involved in choosing routines and goals. The home supported people to develop skills, take part in activities and become more independent.
“Records showed us, and we observed that people were clearly involved with choosing their routines and goals.” from the report
Better staff skills
Staff had received additional training linked to people's individual needs. Inspectors found that staff now had strong knowledge of how to support people.
“Staff had received increased training. This training was specific to people's individual needs.” from the report
Improvements not yet proven over time
needs fixingThe new management systems and ways of working had produced clear improvements, but they were still new. Inspectors wanted evidence that good practice would continue.
“We require longer term evidence that this good quality practice has been sustained and embedded at the service.” from the report
Regular involvement needs checking
needs fixingPeople had been involved in meetings and service improvements, but inspectors wanted this involvement to continue regularly.
“We require evidence that this involvement is sustained and regular.” from the report
Complaints process not tested
minorNo complaints had been received since the previous inspection, so inspectors could not assess how well the home handled a complaint in practice.
“No complaints had been received since the last inspection. So we were unable to assess how the service responded to complaints.” from the report
- 01How do you check that the new care plans and risk guidance remain accurate and up to date?
- 02What happens if the manager is absent, and how are repairs, incidents and safety concerns followed up?
- 03How often are people and relatives involved in meetings and decisions about improvements?
- 04How do you check that staff still have the knowledge and training needed for each person's individual needs?
- 05How are medicines audited, and how would you respond if a medicines error was found?
This was an unannounced planned follow-up inspection covering all five key questions, after the previous Inadequate rating and Special Measures. This explanation was written from the published report of 17 August 2019 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 2019
Rated Inadequate and placed in special measures; inspectors found serious risks in safety, medicines, care planning and management.
This was an unannounced comprehensive inspection on 12 and 17 December 2018. Inspectors observed care, spoke with three people, four care staff and the manager, and checked care records, recruitment files, medicines, incidents, audits and other management records.
The home was not safe. Care plans did not give staff clear guidance, medicines were not managed safely, fire safety and water safety risks were not properly controlled, and the home was unclean. Staff were not always deployed as planned, and some safeguarding incidents had not been referred or reported.
Inspectors found some kind and respectful day-to-day care. People enjoyed meals and activities, and staff understood some people's non-verbal communication. However, staff training, mental capacity assessments, involvement in care planning and longer-term goals needed improvement.
The overall rating was Inadequate. Safe and well-led were rated Inadequate, while effective, caring and responsive were rated Requires Improvement. The home had previously been rated Good in February 2016. After this inspection, the provider sent an action plan and some evidence of changes, but inspectors had not checked whether improvements were effective or lasting.
Kind everyday care
People were generally treated with kindness, compassion, dignity and respect during everyday interactions. Staff recognised some signs of distress and offered support quickly.
“People were treated with kindness and compassion throughout the day” from the report
Food and choice
People were supported to maintain a balanced diet and were involved in choosing meals. Inspectors saw people enjoying their food, with alternatives offered when needed.
“People were supported to maintain a balanced diet” from the report
Positive activities
People took part in activities linked to their interests, including decorating, feeding birds and a voluntary work role. Some people enjoyed spending time out with staff.
“People were provided with some opportunities to follow their interests.” from the report
Privacy and dignity
Staff supported people discreetly and encouraged them to do as much as possible for themselves during personal care.
“People were given privacy and their dignity was respected.” from the report
Unsafe care planning
seriousCare plans and risk assessments were poor, contradictory or missing important information. Staff responses to behaviour and health risks varied and could harm people's wellbeing.
“Care plans did not guide staff on how to respond to people's needs.” from the report
Fire and environmental risks
seriousFire doors and emergency lighting problems had not been resolved. The home was unclean, and water safety checks for Legionella had not been completed as required.
“People had not been protected from the risk of fire for an extended period.” from the report
Medicines not safely managed
seriousSome medicines were out of date, records were incomplete, and medicines prescribed when needed were given without recording the reason. A medicine was also missing from a future blister pack.
“Medicines were not managed safely. This put people at risk of not getting medicines as prescribed.” from the report
Out-of-date staff training
seriousTraining in mental capacity, safeguarding and positive behavioural support had expired for several staff. Inspectors found limited knowledge and unsafe restrictive practices.
“Staff were not sufficiently trained to deliver effective care and support.” from the report
Weak management oversight
seriousKnown problems were not dealt with promptly, audits did not identify significant issues, and incidents were not consistently reviewed or reported. The provider had not shown enough learning or improvement.
“The provider had poor oversight of concerns and there was a failure to resolve known issues” from the report
Limited involvement in planning
needs fixingPeople had historically had little involvement in their care plans and daily routines. A new manager had started making improvements, but these were not yet embedded.
“People have not been adequately engaged with in the service” from the report
- 01Have all care plans and risk assessments been rewritten so staff have clear, consistent guidance, especially about behaviour, seizures and one-to-one support?
- 02What evidence shows that medicines are now stored, recorded and given safely, including medicines prescribed when needed?
- 03Have the fire doors, emergency lighting and water safety arrangements been checked and repaired, and can you show us the records?
- 04How many staff now have in-date training in safeguarding, mental capacity and positive behavioural support?
- 05How are people and their relatives involved in care planning, daily routines and longer-term independence goals?
This was an unannounced comprehensive inspection covering all five key questions, using observations, conversations, care records, recruitment files and management records; end-of-life care could not be assessed because nobody was receiving it. This explanation was written from the published report of 8 March 2019 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 Meadow
3 rated inspections over 4 years: the service has held its Good rating throughout.
- August 2019Goodcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2019Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- May 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- October 2011
Registered with the Care Quality Commission on 31 October 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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