CQC report explained · a nursing home
What the CQC found at Rose Villa Nursing 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, October 2022
Rated Requires Improvement, with an Inadequate well-led rating; inspectors found important gaps in staffing, care records, safeguarding and management oversight.
Inspectors visited the home without notice on 23 and 24 August 2022. They spoke with people, relatives, staff and health professionals. They reviewed care files, medicine records, staff records and the home's quality checks.
The overall rating fell from Good at the previous inspection to Requires Improvement. Safe, Effective and Responsive were rated Requires Improvement. Well-led was rated Inadequate. The report says care was not always based on up-to-date information, staffing was stretched and management systems did not reliably identify or fix problems.
There were some positive findings. Infection prevention arrangements broadly followed current guidance. People had access to food, drinks, outside space and a quiet area for visitors. Staff were described as knowing people well, although records did not always give staff enough information to provide safe, personalised care.
The report identified breaches of legal regulations. The provider was required to send an action plan, and the CQC said it would monitor progress with the provider and local authority.
Infection control
Inspectors found that the home had clear infection prevention procedures and generally followed relevant guidance. Some environmental and PPE issues were dealt with immediately.
“Staff have access to and followed clear policies and procedures on infection, prevention and control that met current and relevant national guidance.” from the report
Food and drink
People had enough food and drink and could choose between hot and cold drinks during the day.
“People had choice and access to enough food and drink throughout the day.” from the report
Suitable environment
The home had communal space, personalised bedrooms, outside space and a quiet area for visitors.
“The environment was suitably adapted to meet people's needs. There was plenty of communal space and bedrooms were personalised.” from the report
Staff knew people
Staff showed that they knew people and could recognise changes in their health or presentation.
“Staff knew people well and understood how to recognise if a person's presentation or health had changed and who they would report this to.” from the report
Staffing and response times
seriousInspectors found that there were not enough staff to meet people's needs. Call bells were not always answered promptly, and staff said they were physically exhausted.
“On both days of inspection, we observed there was not enough staff available. Call bells were not answered in a timely manner.” from the report
Care records and risk information
seriousCare plans and risk assessments did not always reflect people's current needs. Staff did not always have the information needed to manage conditions such as epilepsy, diabetes or falls risks.
“Care records were not kept up to date to reflect people's current needs.” from the report
Safeguarding
seriousSafeguarding procedures were not followed consistently, and not all staff, including some qualified nurses, had completed safeguarding training.
“There was not a consistent approach to safeguarding and matters were not always dealt with in an open and transparent way.” from the report
Consent and capacity
seriousThe home did not consistently assess capacity or record best-interest decisions. People and their relatives were not always involved in decisions about care and treatment.
“Consent was not always appropriately sought.” from the report
Management oversight
seriousAudits did not identify important concerns, and investigations into accidents, incidents and safeguarding matters were not consistently completed. The home also did not always notify the CQC about incidents as required.
“Audits were ineffective and did not identify or prompt action to address the concerns we found with the quality and safety of the service.” from the report
Activities and complaints
needs fixingActivities did not suit everyone, particularly people with different mobility or communication needs. Complaints were handled verbally but were not properly recorded or followed up.
“All complaints should be acknowledged whether they are written or verbal, the provider failed to keep any records of complaints.” from the report
- 01What changes have been made to staffing levels and how do you check that call bells are answered promptly?
- 02How are care plans and risk assessments now kept up to date and made available to every member of staff?
- 03What safeguarding training have all staff and qualified nurses completed, and how are safeguarding concerns now reported and investigated?
- 04How do you assess mental capacity, record best-interest decisions and involve relatives in decisions about care?
- 05What system now records complaints, accidents and incidents, and how do you show that lessons have been learned?
This unannounced inspection covered Safe, Effective, Responsive and Well-led; the report does not give a Caring rating, and the overall rating changed from Good at the 2018 inspection to Requires Improvement. This explanation was written from the published report of 15 October 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.
What inspectors found, March 2018
Rose Villa Nursing Home was rated Good overall; inspectors found kind, safe care, but care records and responses were not consistently reliable.
This was an unannounced inspection on 12 February 2018. Inspectors observed care, spoke with people, visitors, staff and health professionals, checked care and medicine records, and reviewed how the home was managed.
The home was rated Good for safe, effective, caring and well-led. Inspectors found improvements since the January 2017 inspection. Earlier concerns about risk management, consent and governance had been addressed.
The home was rated Requires Improvement for responsive care. Some care plans and monitoring charts did not contain enough information or were not recorded consistently. Inspectors also heard about delays in responding to some requests for help.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw staff maintain privacy and dignity, explain care and offer reassurance.
“People who used the service told us they liked living there, the staff were kind and caring, and they respected their privacy and dignity.” from the report
Safer risk management
Risk assessments had improved and were reviewed more often. A new heating system had also made bedrooms warmer and reduced the need for portable heaters.
“At this inspection we found improvements had been made.” from the report
Good food and health support
People had access to health professionals, menu choices and suitable support at mealtimes. Inspectors saw staff assist people patiently and sensitively.
“Staff were supportive at meal times; they sat next to people and assisted them to eat in a patient and encouraging way.” from the report
Meaningful activities
Two activity coordinators provided planned activities seven days a week. These included group and one-to-one activities based on people's interests.
“There were two activity coordinators who worked 30 and 25 hours a week, which meant there were activities seven days a week.” from the report
Improved management checks
The home used audits, observations, meetings, surveys and action plans to monitor quality and address problems.
“The quality monitoring system had improved with audits and checks identifying areas to be addressed.” from the report
Care records lacked detail
needs fixingTwo of the five care files checked needed more information. Examples included missing fluid targets, limited wound care instructions and incomplete catheter guidance.
“We recommend improvements continue with the recording of care plans and monitoring charts to ensure up to date information to guide staff in meeting people's needs.” from the report
Some monitoring was inconsistent
needs fixingFluid intake was not always recorded consistently. Inspectors also found no clear plan for caring for one person's hand and nails, and a wound dressing had not been recorded.
“The amount of daily fluid intake had not been calculated and staff were unaware of the amount they should aim for; recording of their fluid intake was inconsistent.” from the report
Some medicine protocols missing
minorMost protocols for medicines given when needed were in place, but some were missing. The manager said the records would be checked.
“However, we did find some missing protocols and the registered manager told us they would check the records and ensure all were in place.” from the report
- 01How have you improved the care plans and monitoring charts since this inspection?
- 02How do you calculate and record the daily fluid target for people who need fluid monitoring?
- 03How quickly should someone expect help after pressing the call bell, and how do you check response times?
- 04Have all protocols for medicines given when needed now been completed and checked?
- 05Which staff still need training in mental capacity, wound care, catheter care, end of life care or diabetes management?
This was an unannounced inspection of the overall service and all five key questions, including care, records, staffing, medicines, the environment and management systems. This explanation was written from the published report of 20 March 2018 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 Villa Nursing Home
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- October 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- March 2018Goodup from Requires improvementSafe: GoodEffective: GoodResponsive: Requires improvementWell-led: Good
- February 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2016Inspected but not ratedSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 28 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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