CQC report explained · a nursing home
What the CQC found at Rosevilla Nursing Home
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 care plans were not up to date, and safety monitoring was missing for one person's complex needs. Staffing, recruitment, medicines management and infection control were otherwise found to be satisfactory.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- Management systems had not reliably identified important risks or kept care plans up to date. There was no registered manager in post, although additional managers were supporting the home and an improvement plan was being prepared.
What inspectors found, July 2023
Rated Requires Improvement; inspectors found gaps in care planning, safety checks and management oversight.
This was an unannounced focused inspection on 7 June 2023. Inspectors looked only at Safe and Well-led because concerns had been raised about nursing care and quality checks. They spoke with people, a relative, staff and an external professional, and reviewed care records, medicines records, recruitment files and management documents.
The home had enough staff and medicines were managed effectively. Infection prevention arrangements were satisfactory, staff knew how to report abuse, and lessons were learnt from accidents and incidents. People and relatives said people were safe, although feedback about management was mixed.
Inspectors found that some care plans were out of date and one person's complex needs were not being monitored or managed as required. The home also had no registered manager at the time. Safe and Well-led were both rated Requires Improvement, and the overall rating stayed Requires Improvement. The other three question ratings were carried over from the previous inspection.
Staffing and recruitment
Inspectors found enough staff were available and most recruitment checks had been completed before staff started work.
“People were supported by enough staff who were safely recruited to work at the home.” from the report
Medicines
Medicines records were completed, medicines were stored securely and staff had clear instructions for giving them.
“People's medicines were managed effectively.” from the report
Infection control
Inspectors were assured about infection prevention, the use of protective equipment and the home's response to infection risks.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Learning from incidents
Accidents and incidents were recorded and reviewed for patterns, with referrals made when needed.
“Reviews were then completed to analyse the accidents and incidents to identify themes and trends and help reduce the risk of them happening again.” from the report
Staff culture
Staff described better morale and said managers were sharing information and providing support.
“The morale is improving now, it has lifted. It was previously oppressive.” from the report
Care plans and risk monitoring
seriousSome care plans were out of date. One person's risk assessment was not being followed and their complex needs were not being monitored or managed safely until action was taken during and after the inspection.
“People's care plans were not always up to date, and safety monitoring was not in place for 1 person's complex needs.” from the report
Management oversight
seriousQuality checks had not identified an important safety risk, and some known problems had not yet been fixed. The home also had no registered manager in post.
“The provider's competency checks had failed to identify where a high risk was not being monitored or mitigated as required.” from the report
Registered manager
needs fixingA manager had applied to register but had left before the inspection. The provider was recruiting a new manager.
“At the time of our inspection the service did not have a registered manager.” from the report
Recruitment records
minorReferences for one staff member had not been obtained before they started work. Inspectors found no impact from this delay, and other files checked had the required references.
“For 1 staff member, references from their previous employers had not been obtained prior to their commencement date.” from the report
Medicine stock
needs fixingLarge quantities of some medicines were being kept. The manager had counted the stock and was discussing the issue with the pharmacy.
“We found large quantities of stock were kept for some people's medicines.” from the report
- 01How have you updated care plans since the inspection, and how do you check that staff follow them?
- 02How are complex nursing needs now monitored, and who checks that identified risks are being managed promptly?
- 03Who is currently responsible for the home while you recruit a registered manager?
- 04What progress has been made on the action plan for care plans, safety checks and audits?
- 05Has the medicines stock issue been resolved, and how are medicine quantities now checked?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous inspection. This explanation was written from the published report of 19 July 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, September 2022
Rated Requires Improvement; inspectors found kind, responsive care, but medicines checks and management oversight were not yet consistent.
This was an unannounced comprehensive inspection on 20 July 2022. The inspectors spoke with people, a relative and staff, and reviewed care records and medicines records.
The home was rated Good for Effective, Caring and Responsive. People said they felt safe, staff were kind, their choices were respected, and they could access healthcare and activities.
Safe and Well-led were rated Requires Improvement. Medicines storage checks were not always completed correctly, and some improvements identified by audits had not become consistent staff practice.
The previous inspection had rated Safe Inadequate and Well-led Requires Improvement, with breaches of regulations. Inspectors found significant improvements and said the home was no longer in breach, but further work was needed.
Enough staff
Inspectors found enough staff to meet people's needs without unnecessary waiting. Recruitment checks were also in place.
“There were sufficient staff to ensure people did not have to wait for their care.” from the report
Kind and respectful care
People gave positive feedback about staff. Inspectors saw staff supporting privacy, dignity, choice and independence.
“We saw positive interactions between people and staff and staff clearly knew people well.” from the report
Personalised support
Care plans included people's preferences and interests. People could choose meals, activities and how they spent their time.
“People's care plans were personalised and contained information about their needs and preferences.” from the report
Improvement since the last inspection
The home had improved its risk management, care records, staffing, medicines processes and learning from incidents. Inspectors found it was no longer in breach of regulations.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulations.” from the report
Medicine storage checks
needs fixingStaff did not always record medicine room temperatures or take action when temperatures were too high. The home also did not identify that one medicine was running low before it ran out.
“Staff did not always record the temperature of the rooms people's medicines were stored in” from the report
Improvements not fully embedded
needs fixingAudits identified some problems, but the systems did not always make sure staff corrected them consistently. This included medicine temperature records.
“where improvements had been identified systems had not been effective at ensuring improvements were made and embedded into practice.” from the report
End of life planning
needs fixingSome people did not have end of life care plans covering their needs and wishes. The home had identified this and had an action plan.
“People did not always have end of life care plans in place which explored their needs and wishes.” from the report
Training records
minorNot all staff training was up to date. The home had already identified this and planned to support staff to complete it.
“Not all staff training was up to date.” from the report
No quality surveys yet
minorThe home had not yet sent quality surveys to people, relatives or staff at the time of inspection. It said there was a plan to do this.
“The management team told us they had not yet sent out quality surveys for people, their relatives or staff.” from the report
- 01How do you now check and record medicine room temperatures, and what happens when a temperature is outside the safe range?
- 02How do you check that medicines are ordered before they run out?
- 03Which people still need end of life care plans, and when will these plans be completed?
- 04How do you check that improvement plans have become consistent practice for all staff?
- 05Has the new manager completed registration, and have quality surveys now been sent to people, relatives and staff?
This was the home's first comprehensive inspection and followed an earlier focused inspection; all five key questions were assessed, with Safe and Well-led remaining below Good. This explanation was written from the published report of 24 September 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 Rosevilla Nursing Home
3 rated inspections over a year: the service has held its Requires improvement rating throughout.
- July 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- February 2022Requires improvementSafe: InadequateWell-led: Requires improvement
- May 2020
Registered with the Care Quality Commission on 1 May 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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