CQC report explained · a residential care home
What the CQC found at Rosebank Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, May 2023
Rated Requires Improvement; inspectors found clear improvements and ended special measures, but safety and leadership were not yet consistently reliable.
This was an unannounced, focused inspection. Inspectors visited on 5 April 2023 and reviewed information through 12 April 2023. They spoke with people, staff and managers, observed care, and checked care plans, medicines records, recruitment files and management audits.
The home had improved since its previous inspection, when it was rated Inadequate and placed in special measures. Inspectors found that earlier problems about consent, safeguarding, governance and incident notifications had been addressed. The home was no longer in breach of those requirements.
However, Safe and Well-led were both rated Requires Improvement. Inspectors said there was still limited assurance about safety and that management and leadership were not yet consistent. The overall rating changed from Inadequate to Requires Improvement, but the other three question ratings were carried forward because they were not inspected.
Better risk planning
People had updated, detailed care plans covering risks such as behaviour, communication, moving and handling, falls and choking.
“People now had up to date care plans that contained detailed person-centred risk assessments and management plans to help staff keep people safe.” from the report
Medicines were managed safely
Inspectors found medicines were administered, stored, disposed of and checked safely. They found no recording errors or omissions in the records reviewed.
“We found no recording errors or omissions on any medicines records we looked at.” from the report
Enough suitable staff
Staffing levels matched people's needs, with flexible staffing and little reliance on agency workers. Recruitment checks were described as thorough.
“There were now enough staff to safely meet people's care and support needs.” from the report
Improved oversight
The provider introduced electronic governance systems, regular visits and audits to identify problems and track improvements.
“The service has improved and was moving in the right direction through continuous learning.” from the report
Safety was not consistently assured
seriousSafe was rated Requires Improvement. CQC said some aspects of the service were still not always safe and there was an increased risk of harm.
“This meant some aspects of the service were still not always safe and there was limited assurance about safety.” from the report
No registered manager
needs fixingThere was no registered manager in post when inspectors visited. A new acting manager had been appointed, but was due to start after the inspection.
“The service remains without a registered manager which the provider is required to have in post to oversee the delivery of regulated activities at this location.” from the report
Improvements need to last
needs fixingCQC did not rate the home Good because it needed to see consistent good practice over time. Leadership and management were still described as inconsistent.
“We could not improve the rating from inadequate to good because to do so requires consistent good practice over time.” from the report
- 01Who is now responsible for the home day to day, and when will the new acting manager apply to become registered?
- 02What checks are being used to make sure the improvements to risk assessments and care plans continue?
- 03How will you show that safety and leadership have become consistent since this inspection?
- 04What action is being taken in response to the Requires Improvement ratings for Safe and Well-led?
- 05How will families be kept informed about progress before the next CQC inspection?
This was a focused inspection of Safe and Well-led, including infection prevention and control; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 10 May 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, November 2022
Rated Inadequate and placed in special measures; inspectors found unlawful restrictions, unsafe practice and weak oversight.
This was an unannounced inspection on 15 and 22 July 2022. Inspectors observed care, spoke with relatives, staff and a professional, and reviewed care, medicines, staff and management records. The inspection was prompted partly by concerns about people being unlawfully deprived of their liberty.
Inspectors found people were locked in bedrooms without proper authorisation, and one person was unlawfully restrained. Incidents were not always recorded, reported or investigated. Risk assessments were not clear or up to date, and there were concerns about some medicines records.
The home was rated Inadequate for Safe and Well-led. The report says these ratings had fallen from Good at the previous inspection. The home was placed in special measures, meaning CQC will keep it under review and normally re-inspect within six months if it does not propose cancelling the provider's registration.
Infection control
Inspectors were assured that infection prevention arrangements were in place, including visitor safety, PPE, testing, hygiene and outbreak planning.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Recruitment checks
The staff files reviewed contained employment histories, references, identification and DBS checks.
“The provider had systems in place to ensure all employed staff underwent robust recruitment processes to ensure their suitability for the role.” from the report
Immediate improvement plan
After the inspection, senior management increased its presence, arranged urgent training and submitted an action plan addressing the concerns.
“The management team recognised the areas that required improvement amongst the service and had developed an immediate, comprehensive action plan” from the report
Unlawful restrictions and restraint
seriousPeople were locked in bedrooms without the required legal authorisation. Inspectors also observed physical restraint being used as a first response rather than a last resort.
“People were being deprived of their liberty unlawfully.” from the report
Incidents not properly recorded
seriousFifty-three incident and body map records had not been properly reported or investigated. Restraint incidents were also not documented, so the home could not learn reliably from what happened.
“The incident forms were not completed appropriately and had not all been reviewed by senior staff to identify patterns and trends in order to prevent reoccurrence.” from the report
Unclear risk assessments
seriousSome assessments did not give staff clear instructions about choking risks or how to support people when they were anxious, distressed or overwhelmed.
“The risk assessment was unclear and did not give staff adequate guidance on how to effectively meet their needs whilst initiating de-escalating techniques.” from the report
Closed culture and poor communication
needs fixingInspectors found weak leadership and a culture where staff were reluctant to report poor practice. Relatives said communication was poor and they were not consistently asked for their views.
“People received care and support from a service that had an embedded closed culture amongst the team working within the service.” from the report
- 01How do you now check that every restriction on a person's movement is legally authorised, including any use of bedroom doors?
- 02How are restraint and other incidents recorded, reported to the right authorities and reviewed for patterns?
- 03What changes have been made to risk assessments for choking and for people who become anxious or distressed?
- 04How are medicines records and homely remedies now checked for accuracy and possible contraindications?
- 05Who is overseeing the action plan, and what evidence can you show that the improvements have been sustained since the inspection?
This was an unannounced inspection focused on Safe and Well-led; the report gives no ratings for Effective, Caring or Responsive. This explanation was written from the published report of 15 November 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 Rosebank Lodge
8 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- May 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2022Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- February 2022Goodstayed GoodSafe: GoodWell-led: Requires improvement
- August 2019Goodstayed GoodSafe: GoodWell-led: Good
- December 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Good
- December 2015Requires improvementstayed Requires improvementEffective: Requires improvement
- March 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Good
- September 2020
Registered with the Care Quality Commission on 21 September 2020.
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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