CQC report explained · a residential care home
What the CQC found at Rosedale Care Home Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe, staffing levels had increased, and medicines, recruitment and infection control were found to be managed safely. Inspectors said the premises had been made safe and legal requirements were met.
- Effective?
- Good
- This key question was not rated in this inspection.
- Caring?
- Good
- This key question was not rated in this inspection, although inspectors described good relationships and friendly conversations between people and staff.
- Responsive?
- Good
- This key question was not rated in this inspection, although people were supported with their interests, communication methods, choices and community activities.
- Well-led?
- Good
- New daily, weekly and monthly audits were in place, and shortfalls found through them were addressed. Inspectors noted that ABC charts had not yet been formally audited and there was no formal improvement plan.
What inspectors found, April 2022
Rosedale Care Home Limited: Rated Good; inspectors found safe, person-centred care, with some records still needing improvement.
Inspectors visited without notice on 24 February 2022. They spoke with four people, managers and care workers, and reviewed care, medicine, staffing, recruitment and management records.
The home was rated Good overall, with Good ratings for Safe and Well-led. People were supported to make choices, stay active and use community facilities. Inspectors saw warm relationships between people and staff.
The inspection was prompted partly by concerns about medicines and people's finances. Inspectors found medicines were managed safely and financial transactions were recorded. They also found that improvements had been made since the previous Requires Improvement rating, and the home was no longer in breach of regulations.
Choice and independence
People chose how their rooms looked, followed their own interests and were supported to make safe choices and go out in the community.
“People chose their own décor and displayed items and pictures that were important to them.” from the report
Kind relationships
Inspectors saw friendly and humorous conversations. People said staff supported them well and understood how they preferred to communicate.
“Relationships between people and staff were good and we saw friendly and humorous conversations taking place.” from the report
Safe staffing
There were three care workers during the day and two at night, with managers also working at the home every day. Recruitment checks were completed.
“There were plenty of staff on duty to meet people's needs.” from the report
Medicines management
Staff were trained, medicines were stored securely and records showed people received them when needed. Weekly and monthly audits were carried out.
“Medicines were audited weekly by the deputy manager, and monthly by the registered manager.” from the report
Improved oversight
The new audit system covered care, health and safety and staffing. Records showed that identified shortfalls were put right.
“At this inspection a new audit system was in place.” from the report
Accident records
needs fixingThe accident book included some health conditions that were not accidents. The manager said it would be reviewed and staff would be reminded what to record.
“It contained information about minor accidents, but also some health conditions that would be better placed in people's care notes as they were not the result of an accident.” from the report
Behaviour records
needs fixingABC charts had not been formally audited to identify themes and trends. Managers said this would be added to the audit system.
“ABC (antecedent, behaviour, consequence) charts hadn't been audited to identify themes and trends.” from the report
No formal improvement plan
minorThe home did not have a formal improvement plan, although managers described planned bathroom and bedroom upgrades.
“The service did not have a formal improvement plan, however, managers told us they were planning to upgrade one of the bathrooms and one person's bedroom.” from the report
- 01What changes have been made to the accident book, and how do you check that staff record only accidents, incidents and near misses there?
- 02How are ABC charts now audited, and what would you do if they showed a repeated cause of distress?
- 03What were the concerns about medicines and people's finances that prompted this inspection, and how do you monitor these areas now?
- 04What is the timetable for the planned bathroom and bedroom upgrades?
- 05What ratings would you give the service for Effective, Caring and Responsive, which were not rated in this inspection?
This was a focused inspection of Safe and Well-led, prompted partly by concerns about medicines and finances; the other key questions were not rated in this report. This explanation was written from the published report of 30 April 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, October 2020
Rosedale Care Home Limited was rated Requires Improvement after inspectors found safety and management weaknesses, although people described kind care and safe medicines.
This was a focused inspection on 29 and 30 July 2020. One inspector spoke with four people, two relatives and five staff, and checked care, medicines, recruitment and management records. The inspection followed an allegation of abuse, but the circumstances were not examined because of a criminal investigation.
The home was rated Requires Improvement for Safe and Well-led. Inspectors found that some windows were not properly restricted, some abuse allegations had not been referred to the local safeguarding team, and legally required notifications had not been sent to CQC. Management checks had not found these problems.
There were also positive findings. People said staff were kind, medicines were given as prescribed, staff followed Covid-19 infection control guidance, and recruitment checks had been completed. The overall rating fell from Good at the previous inspection in November 2018.
After the inspection, the home said window restrictors had been installed, the electronic care-record problem had been corrected, and its checking systems had been reviewed. CQC said it would request an action plan, monitor progress and return to inspect again.
Kind and caring staff
Inspectors saw positive interactions. People said staff were kind, caring and reassuring.
“We observed kind and caring interactions between staff and people.” from the report
Medicines
Records showed that people received their medicines as prescribed. Staff understood people's medicines and preferences.
“Medicine Administration Records (MARs) indicated people had received their medicines as prescribed.” from the report
Infection control
Staff used the expected protective equipment and showed good awareness of reducing Covid-19 transmission. The home was clean and free from bad smells.
“Staff demonstrated good awareness of infection control requirements to minimise the risk of transmission of Covid-19.” from the report
Safe recruitment and responsive staffing
Recruitment checks had been completed. Inspectors saw staff respond promptly and people were supported by a consistent team who knew them well.
“People were supported by a consistent team of staff that knew them well.” from the report
Window and safeguarding risks
seriousWindows were not adequately restricted to reduce the risk of falls. Records also showed that not all abuse allegations had been referred to the local safeguarding team.
“Systems and processes had not identified windows were not adequately restricted to reduce the risk of people falling from height” from the report
Weak management checks
seriousThe home's quality checks did not identify several safety and governance problems. This was a breach of Regulation 17.
“We found no evidence that people had been harmed however, systems were either not in place or robust enough to demonstrate the regulatory activity was effectively managed.” from the report
Care records and training
needs fixingThe home could not initially download or print electronic care records for other professionals. Required training was not always completed within the home's stated yearly timeframe.
“The service was unable to download or print people's electronic care records at the time of the inspection.” from the report
Unclear legal safeguards
needs fixingStaff gave different information about which people had Deprivation of Liberty Safeguards authorisations. Inspectors said this created a risk that people's rights might not be upheld.
“DoLS ensures people who cannot consent to their care arrangements are protected if arrangements deprive them of their liberty” from the report
- 01Have all window restrictors now been fitted and checked as safe?
- 02How are abuse allegations now recorded and referred to the local safeguarding team?
- 03What checks are being used to make sure legally required CQC notifications are sent on time?
- 04Can you show how electronic care records can now be downloaded or printed for visiting health professionals?
- 05How are you ensuring compulsory training and Deprivation of Liberty Safeguards records are kept up to date?
This was a focused inspection of Safe and Well-led only; the other key questions were not inspected and previous comprehensive inspection ratings were used in calculating the overall rating. This explanation was written from the published report of 10 October 2020 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 Rosedale Care Home Limited
4 rated inspections over 6 years: the service has held its Good rating throughout.
- April 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2020Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- November 2018Goodstayed GoodSafe: GoodWell-led: Good
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 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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