CQC report explained · a residential care home
What the CQC found at Rosedale House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk plans, safeguarding records, staff training records, medicine checks and infection control arrangements were not always complete or up to date. Inspectors found enough permanent staff and said medicines were generally given as prescribed.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Requires improvement
- Care plans included people's preferences, but some information was not accurate or current. Goals, communication support and involvement of families in care reviews needed to improve.
- Well-led?
- Requires improvement
- The manager covered four homes while senior vacancies remained. Audits, care plan reviews, incident follow-up and training oversight were not effective enough, leading to a breach of Regulation 17.
What inspectors found, August 2023
Requires Improvement; inspectors found caring and consistent staff, but gaps in safety checks, care reviews and management oversight.
This was an unannounced focused inspection. Inspectors visited on 16 and 18 May 2023, with inspection work ending on 6 July 2023. They spoke with relatives, a person using the service, staff and health professionals. They observed care and checked care, medicine, recruitment and management records.
The home supported two people with learning disabilities and autism. Staff knew people well and provided kind, person-centred support. People took part in activities, family visits and community trips. However, risk plans, care reviews, training records, safeguarding records and medicine checks were not always complete or up to date.
The home was rated Requires Improvement overall. Safe, Responsive and Well-led were also rated Requires Improvement. Effective and Caring were not inspected during this visit, so their previous ratings were carried forward. The overall rating fell from Good at the previous inspection, published in July 2019.
The provider had breached Regulation 17 on good governance. After the inspection, the manager supplied some missing reviews, submitted notifications and created a service development plan. CQC said further monitoring and improvement were needed.
Consistent staff
A permanent staff group worked regularly with people and knew their needs well. Inspectors said this helped provide person-centred care that respected privacy and dignity.
“There was a permanent staff group who worked consistently with people, so they knew them well” from the report
Family contact
The home supported home visits, family holidays and important family occasions. Relatives valued the extra staffing arranged to make these visits possible.
“They always go out of their way to put extra staff on to bring [person] home.” from the report
Activities and achievements
People took part in local activities and achieved goals such as healthier eating, family reconnection, holidays and visits. The home had also developed a summer house for arts and crafts.
“People were supported to take part in activities and interests in the local area.” from the report
Support from specialists
Specialist professionals worked with staff to understand people's needs and improve consistency. Inspectors received positive feedback about the staff team's work with professionals.
“Overall this is a very caring and thoughtful staff team who have worked really well with professionals” from the report
Out-of-date risk information
seriousSome risk and positive behaviour support plans were not complete or current. Important changes in support had not been added, and some plans had not been reviewed when they should have been.
“People had plans in place to assess and manage their risks. However, we found these were not always up to date and complete” from the report
Weak management checks
seriousAudits and monitoring did not reliably identify or resolve problems. The manager's responsibility for four homes and vacancies in senior roles affected oversight.
“Quality assurance arrangements were not always applied consistently or were effective.” from the report
Incomplete incident reporting
seriousNot all incidents were reported to the local authority or CQC as required. Some staff incidents and near misses were not recorded, so inspectors could not be sure that all lessons had been learned.
“Incidents forms were not completed for all incidents or near misses involving staff” from the report
Care review involvement
needs fixingCare plan reviews were carried out by the manager alone in some cases. Meetings involving relatives and professionals had also stopped for about a year for one person.
“There had been a lack of involvement of others including family in the reviewing of care plans.” from the report
Cleaning and maintenance
needs fixingSome living areas were cluttered and cleaning schedules had gaps. Inspectors also found a loose radiator cover and an unsecured wardrobe that were not on the maintenance list.
“The service did not always meet current national guidance and standards in relation to infection control.” from the report
- 01How have you updated each person's risk and positive behaviour support plan, and how often are they now reviewed?
- 02What checks now make sure all safeguarding concerns, incidents and near misses are recorded and reported correctly?
- 03How are relatives and health professionals involved in care reviews and best-interest decisions?
- 04What has changed in the manager's workload and senior staffing since the inspection?
- 05How do you now check that medicines are counted and recorded when they move between homes?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 4 August 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, July 2019
Rated Good overall; inspectors found kind, person-centred care, but the home's leadership and quality checks required improvement.
This was a planned inspection by one inspector on 29 May 2019. The inspector spoke with one person, observed care for both people living there, spoke with managers and staff, and checked care, medicine, recruitment and management records.
The home was rated Good for being safe, effective, caring and responsive. Inspectors found enough trained staff, safe medicines, kind support, personalised care and good links with health professionals.
The Well-led rating fell from Good at the previous inspection to Requires Improvement. Quality checks had not found some safety risks and record-keeping problems. The manager took action after the inspection, including improving emergency plans, arranging an electrical safety check and monitoring night checks.
Kind and respectful support
Inspectors found staff to be compassionate and respectful. People were encouraged to make choices, maintain privacy and develop independence.
“Staff showed empathy, kindness and compassion; they placed value on their caring roles and involvement in people's lives.” from the report
Choice and community life
People took part in activities and spent time in the local community. Staff supported meaningful activities and personal goals.
“People living at Rosedale House participated in activities and were actively involved in their local community.” from the report
Personalised communication
Care and communication plans gave staff detailed guidance about people's needs, wishes and daily support.
“Communication plans were in place, providing detailed guidance for staff to ensure people were able to express their wishes, preferences and daily needs.” from the report
Medicines managed safely
Inspectors found medicines were ordered, supplied and given as prescribed. Staff had medicine training and audits were completed.
“People's medicines were managed safely. Processes were in place for the timely ordering and supply of medicines.” from the report
Safety risks were not identified promptly
seriousInspectors found unprotected first-floor windows, unsecured large furniture and an out-of-date electrical safety certificate. The manager took action after the inspection, but these checks should have identified the risks sooner.
“We found windows on the first floor without restrictors in place and unsecured large items of furniture.” from the report
Night-time emergency planning
seriousThe service had not fully assessed how one staff member working at night would support people during an emergency. There had also been no fire drills in the previous six months.
“Risks relating to having one member of staff on shift at night, and how they would support people in the event of an emergency” from the report
Quality checks and records
needs fixingThe management team was still building its audit system. Some environmental risks and documentation inconsistencies had not been found through existing checks.
“some inconsistencies in documentation that had not been identified through the quality checks and audits already in place.” from the report
End of life planning
minorNo one needed end of life care during the inspection, but care records did not contain specific end of life plans. Inspectors said this area would benefit from further development and staff training.
“People's care records did not contain specific end of life care plans” from the report
- 01Have the first-floor windows, unsecured furniture and electrical safety issues identified during the inspection all been resolved?
- 02How do you protect people when one staff member is working at night, especially during a fire or other emergency?
- 03How often are fire drills now carried out, and do they reflect each person's communication and support needs?
- 04What quality audits are now in place, and how do managers check that records and safety risks are being properly reviewed?
- 05How would you involve a person and their family in planning end of life care?
This was a planned inspection covering all five questions, the premises and the care provided. This explanation was written from the published report of 6 July 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 Rosedale House
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- August 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2019Goodstayed GoodSafe: GoodResponsive: GoodWell-led: Requires improvement
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 12 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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13 live-in carers within about an hour of Norfolk
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 £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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