CQC report explained · a residential care home
What the CQC found at Rosenmanor 1
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some people's risks were not properly assessed or supported by clear guidance. Inspectors also found concerns about excessively long shifts and PPE use, although there were enough staff on duty and medicines were given as prescribed.
- Effective?
- Requires improvement
- Staff did not always receive regular supervision and appraisal. Training was up to date, and people were supported with food, healthcare and decisions about their care.
- Caring?
- Requires improvement
- Staff were often kind and supported people's independence and choices. However, inspectors found that staff did not always respect people's privacy when entering bedrooms.
- Responsive?
- Requires improvement
- Care plans were personalised and communication needs were recorded and supported. People were not always offered enough meaningful social and leisure activities.
- Well-led?
- Requires improvement
- The provider had monitoring systems and an open approach to people's views, but these systems did not identify or deal with several safety, staffing, privacy, maintenance and activity issues.
What inspectors found, December 2022
Rated Requires Improvement; inspectors found kind, personalised care, but gaps in risk management, privacy, staff support and oversight placed people at risk.
Inspectors visited on 18 October and 2 November 2022. The first day was unannounced. They spoke with people living at the home, relatives, staff and the registered manager. They also checked care plans, medicines records, staff files and management records.
The home was not always safe or well managed. Risk assessments were missing for some people, including people living with dementia or visual impairment. Staff worked an excessively long shift, some did not wear PPE, and staff did not always knock before entering bedrooms. Staff also lacked regular supervision.
There were good features. People received their medicines as prescribed, had enough staff supporting them, and had personalised care plans. People described staff as kind, and inspectors found that people were supported with food, healthcare, independence and communication.
All five areas were rated Requires Improvement. This means the care was not consistently safe, effective, caring, responsive or well led. The rating had fallen from Good at the previous inspection, published on 26 August 2021.
Enough staff on duty
Inspectors saw enough staff available during the visit to meet people's needs and respond to requests. The provider said there were no staff vacancies at the time.
“Staff were visibly present throughout this two-day inspection and we saw there were enough staff on duty to meet people's needs and to keep them safe.” from the report
Medicines were given correctly
People received their prescribed medicines, and medicines records had no recording errors or omissions. However, guidance for medicines given when needed was not detailed enough.
“People received their medicines as they were prescribed.” from the report
Personalised care plans
Care plans included people's needs, preferences, strengths and communication requirements. They were reviewed and updated with people's involvement.
“People's electronic care plans were up to date, personalised and contained detailed information about their strengths, likes and dislikes” from the report
Kind and respectful care
People were generally treated with kindness and their cultural and spiritual needs were recorded. Staff supported people to maintain independence and make choices.
“People looked at ease and comfortable in the presence of staff. Staff interaction with people was characterised by kindness.” from the report
Food and healthcare support
People were supported to access food and drink that suited their needs and preferences. Staff also helped people attend health appointments and access community professionals.
“People were supported to access food and drink that met their dietary needs and wishes.” from the report
Missing risk guidance
seriousSome people's needs and risks had not been properly assessed. Staff lacked important guidance for supporting people with dementia or visual impairment, and some personal emergency evacuation plans were missing.
“there were no risk assessments or management plans in place for staff to follow and safely support people living with dementia or who were visually impaired.” from the report
Excessively long shifts
seriousOne staff member worked a prolonged 24-hour period without a break. The provider said staff would no longer be allowed to work 24-hour shifts without enough time off.
“we found 1 member of staff had worked a prolonged 24-hour period without a break.” from the report
Privacy was not always respected
seriousInspectors saw staff enter bedrooms without knocking or waiting for permission. People said this happened commonly.
“We observed several instances of staff not knocking on people's bedroom doors or waiting to be invited in by the occupant.” from the report
Limited social activities
needs fixingPeople were not always offered enough meaningful activities based on their interests. Inspectors did not see staff encouraging activities during the first day.
“People were not always offered sufficient opportunities to choose to participate in meaningful leisure and recreational activities that reflected their social interests and needs.” from the report
Insufficient staff supervision
seriousMost staff had not had individual or group supervision for more than six months. Not all staff had received the annual appraisal required by the provider's own policy.
“most staff had not had an individual or group supervision meeting with their line manager for over six months” from the report
Premises needed repairs
needs fixingInspectors found maintenance problems, including a missing floor tile, missing furniture handles and an unsuitable sheet covering a bedroom window. The provider said these repairs would be completed by the end of 2022.
“the care home's physical environment and interior décor was not always being appropriately maintained.” from the report
- 01What risk assessments and management plans are now in place for people living with dementia or visual impairment?
- 02How do you make sure staff do not work 24-hour shifts without enough rest?
- 03What checks now confirm that staff knock and wait for permission before entering bedrooms?
- 04What supervision and appraisal schedule is in place for all staff?
- 05What meaningful social activities are now available, and how are they matched to each person's interests?
This was a two-day full inspection of the care and premises, unannounced on the first day, and it assessed all five CQC questions. This explanation was written from the published report of 7 December 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, August 2021
Rated Good; inspectors found safer medicines management and improved staff training, with some infection risk assessments still needed.
This was an unannounced focused inspection on 8 July and 4 August 2021. Inspectors checked Safe, Effective and Well-led because problems had been found at the previous inspection. They spoke with four residents, staff, the manager and relatives, and reviewed care plans, medicine records, staff files and management records.
The home had improved since its previous Requires Improvement rating. Medicines were recorded correctly, staff had completed the required training, and management checks were working better. Residents said they were satisfied with the care and felt safe.
The home was rated Good overall, and Good for Safe, Effective and Well-led. Caring and Responsive were not assessed during this visit, so their earlier ratings were carried forward.
Medicines managed safely
Medicines records were complete and organised. Staff were trained and their medicines work was checked routinely.
“No recording errors or omissions were found on any of the completed MAR sheets we looked at.” from the report
Staff training improved
Staff had completed the training needed to support residents, including basic life support training. Staff also received supervision and further training.
“Staff had completed all the training they required to meet people's needs, including basic life support.” from the report
Residents felt safe
Residents said they felt safe, and staff understood safeguarding responsibilities and how to report concerns.
“People told us they felt safe living at the care home.” from the report
Good management oversight
The manager could provide requested records quickly. Audits and action plans were used to monitor medicines, cleanliness and service quality.
“The quality and safety of the service people received was routinely monitored by managers and senior staff.” from the report
Stable staffing
There were enough staff, few vacancies and low staff turnover. This supported continuity for residents.
“This meant the service was not reliant on temporary agency staff, which helped ensure people received continuity of care” from the report
Staff infection risk assessments
needs fixingThe provider had not recorded infection risk assessments or management plans for staff who might be at higher risk from COVID-19, including staff with underlying health conditions or from Black, Asian and Minority Ethnic groups.
“However, the provider had not carried out infection risk assessments in relation to staff working at the care home.” from the report
Staff appraisals overdue
needs fixingMost staff who had worked at the home for more than 12 months had not received a formal appraisal in the previous year. The manager agreed this would be completed by the end of 2021.
“However, most long-standing members of staff had not had their overall work performance formally appraised in the last 12 months” from the report
- 01Have all staff infection risk assessments and management plans now been completed, including for staff with underlying health conditions?
- 02Were all long-standing staff given a formal performance appraisal by the end of 2021?
- 03What were the previous ratings for Caring and Responsive, which were not assessed during this inspection?
- 04How often are medicine records audited, and what happens if an error is found?
- 05How are residents and relatives involved in reviewing care and suggesting improvements?
This was an unannounced focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 26 August 2021 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 Rosenmanor 1
6 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- December 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2021Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- June 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2017Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- November 2011
Registered with the Care Quality Commission on 7 November 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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