CQC report explained · a residential care home
What the CQC found at Rosenmanor Limited
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People's individual risks, medicines, staffing and infection control were managed well in several areas. But environmental hazards were not always identified or dealt with promptly, including radiator, garden, boiler room and laundry risks.
- Effective?
- Good
- People's needs and choices were assessed, staff were trained and supervised, and people received support with food, activities and healthcare. Mental capacity and best-interest processes were also in place.
- Caring?
- Good
- People said staff were kind and caring. Staff respected privacy, supported independence, recognised cultural and spiritual needs, and involved people in decisions about their care.
- Responsive?
- Good
- Care was personalised around people's needs and preferences. People were supported with communication, relationships, activities, cultural needs, complaints and regular keyworker meetings.
- Well-led?
- Requires improvement
- New audits, action plans and management support had led to improvements. However, the provider's quality checks had not identified important safety problems, so the provider remained in breach of good governance requirements.
What inspectors found, April 2024
Rosenmanor Limited rated Requires Improvement overall; safety and management checks still had important gaps, but the home is no longer in Special Measures.
Inspectors visited without notice on 4 and 7 July 2023. They spoke with people and staff, reviewed care records, staff files, medicines and audits, and checked the building, fire safety, infection control and food safety.
The home had improved since the previous inspection. Medicines were managed safely, care was kind and personalised, and people were supported with activities, healthcare and independence. The ratings for Effective, Caring and Responsive were Good.
However, inspectors found hazards including uncovered or damaged radiator covers, unsafe garden furniture, trip risks and an unsafe boiler room. The home's own checks had not found these problems. The ratings for Safe and Well-led were Requires Improvement, and the home remained in breach of Regulations 12 and 17.
The previous overall rating was Requires Improvement, and the home had been in Special Measures since January 2023. It is no longer in Special Measures because it is no longer rated Inadequate overall or for any key question. CQC said it will continue to monitor the home.
Safer medicines
Medicines were stored securely and given as prescribed. Records had no gaps, and staff had clear guidance for creams and medicines given when needed.
“People's medicines were stored safely in a locked medicines trolley which was tethered to a wall.” from the report
Kind and respectful care
People described staff as kind. Inspectors saw staff respect privacy, knock before entering bedrooms and support people to build independence.
“We observed that staff knocked on people's bedroom doors and waited for permission before entering.” from the report
Personalised support
Care plans included people's choices, worries, communication needs and cultural needs. People took part in reviews and chose how to spend their time.
“People received care and support that was planned around their needs and preferences.” from the report
Improved infection control
The home was clean, bathrooms had no evidence of leaks, damp or mould, and water safety checks had been introduced. The provider was no longer in breach of this part of Regulation 12.
“At this inspection we found that enough improvement had been made and the provider was no longer in breach of this part of regulation 12” from the report
Good support from other services
Staff worked with healthcare professionals, social workers, local authorities and mental health services to support people's changing needs.
“The management and staff worked collaboratively with others to meet people's needs.” from the report
Environmental safety hazards
seriousInspectors found people could be harmed by uncovered or damaged radiator covers, unsafe garden furniture, trip hazards and an unsafe boiler room. Some problems were fixed during the inspection, but further work still needed checking.
“The providers failure to ensure that the premises is safe is a continued breach of regulation 12” from the report
Quality checks missed risks
seriousThe provider's own audits did not identify several safety problems before inspectors found them. This meant the provider remained in breach of Regulation 17.
“The failure to assess, monitor and improve the quality and safety of the service is a continued breach of Regulation 17” from the report
Some improvements were not complete
needs fixingItems remained in a fenced-off garden section, and the provider still had to confirm that appropriate flooring and a step had been installed in the boiler room.
“We will be checking to confirm that safe flooring and an appropriate step have been installed.” from the report
- 01Have all four uncovered radiators and the damaged radiator covers been replaced with sturdy covers?
- 02Has the unsafe garden furniture been removed, and have all remaining garden items and trip hazards been dealt with?
- 03Has the boiler room been fitted with safe flooring and an appropriate step, and is it kept safely restricted?
- 04How often are environmental safety checks now carried out, and who confirms that problems are fixed?
- 05What action is being taken in response to the Regulation 17 Warning Notice?
This was an unannounced comprehensive inspection covering all five key questions, including infection prevention and control, and checking progress after the previous inspection. This explanation was written from the published report of 25 April 2024 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, January 2023
Rosenmanor Limited: Rated Inadequate and placed in special measures after inspectors found serious safety and management failures.
This was an unannounced inspection on 02 September 2022. Inspectors spoke with people, staff and the registered manager. They reviewed care records, staff recruitment files, medicines records, incident records and audits. They also checked the building and gardens.
Inspectors found serious risks to people's safety. These included unsuitable window restrictors, uncovered and damaged radiators, weak fire and water safety arrangements, poor repairs, infection risks and unsafe waste drainage. Medicines were not always properly accounted for, and safeguarding and legal authorisations were not managed correctly.
Staff were described as kind and knew people well. However, people's privacy and dignity were not always protected. The provider's checks and management systems had failed to find or fix many of the problems. The overall rating was Inadequate. Safe and well-led were Inadequate, while caring Requires Improvement.
The service was placed in special measures. The CQC said it would re-inspect within six months if it did not propose cancelling the provider's registration. It said that continued inadequate ratings could lead to action to prevent the home from operating.
Kind and knowledgeable staff
People said staff were kind and caring. Staff understood people's backgrounds, needs and preferences.
“Staff we spoke with understood people's backgrounds, those who were important to them and their needs and preferences well.” from the report
Personalised care
Care was planned around people's mental health needs. Keyworkers and regular meetings helped involve people in decisions about their care.
“Staff knew people well, delivering care day to day in a person-centred way.” from the report
Enough staff
Inspectors found there were enough staff to care for people safely.
“There were enough staff to care for people safely, although one person told us they would like staff to spend more time taking them outside the home.” from the report
Links with health services
The home worked with mental health care coordinators and helped people access other health and social care professionals.
“Most people had regular contact with their mental health teams who advised on the best ways to help people maintain good mental health.” from the report
Unsafe building and fire arrangements
seriousPeople faced risks from missing window restrictors, uncovered and damaged radiators, poor repairs, an uneven garden and concerns about fire and water safety.
“People were at increased risk of falls from windows as the provider had not ensured suitable window restrictors were in place across the service.” from the report
Medicines were not fully controlled
seriousOne medicine was missing and the provider could not account for it. Records and storage arrangements were not always safe, including medicines given covertly without a clear protocol.
“One medicine for one person was missing and the provider could not account for this.” from the report
Safeguarding and legal safeguards
seriousStaff and management did not fully understand safeguarding responsibilities. A person was unlawfully detained without the required legal authorisation, according to a health and social care professional.
“A health and social care professional told us a person had been unlawfully detained since March 2022 because the provider had not ensured a DoLS was in place.” from the report
Poor management oversight
seriousAudits did not identify or resolve many of the problems. The registered manager divided time between three homes, and inspectors found this arrangement was ineffective.
“Although there were some audits in place these were ineffective as they had not identified or resolved the issues we found” from the report
Privacy and dignity
seriousGlass panels in two bedroom doors allowed people outside to see in. Staff did not always knock before entering rooms, and one person had been sleeping on a mattress still covered in plastic.
“Two people had glass panels in their bedroom doors meaning anyone outside could see directly in.” from the report
Limited choice and activities
minorOne person said there was little to do and wanted more trips into the community. The menu showed only one option at each mealtime.
“There is nothing to do, all we do is sleep and sleep and sleep, no monopoly, no scrabble, no nothing.” from the report
- 01Which window restrictors, radiator covers, fire safety measures and building repairs have now been completed, and when were they checked?
- 02How are medicines now counted, stored and recorded, including medicines taken out of the home or given covertly?
- 03What safeguards are now in place to prevent unlawful detention and to report safeguarding incidents promptly?
- 04Who is providing day-to-day management oversight, and how are audits checked to make sure problems are actually fixed?
- 05What has changed to protect people's privacy, provide more activities and offer genuine choices at mealtimes?
This was an unannounced focused inspection of Safe, Caring and Well-led; Effective and Responsive were not inspected and their ratings were carried over from the previous inspection. This explanation was written from the published report of 7 January 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.
Every inspection of Rosenmanor Limited
4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- April 2024Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2023Inadequatedown from GoodSafe: InadequateCaring: Requires improvementWell-led: Inadequate
- July 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- February 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 14 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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