CQC report explained · a residential care home
What the CQC found at Rosevilla Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2024
Rated Inadequate and placed in special measures; inspectors found serious safety and leadership failures despite kind care from staff.
This was an unannounced focused inspection on 29 November and 4 December 2023. Inspectors spoke with people, relatives and staff, and checked care records, medicines records, staff files and management records.
The home was not always safe. Medicines were not managed properly, risks were missing from care plans, accidents were not analysed and staffing was not always enough. Inspectors also found gaps in consent records and care planning.
Staff were often described as kind and caring, and people and relatives spoke positively about them. However, management checks had failed to find or fix important problems. The overall rating fell from Good at the last inspection to Inadequate.
The home is in special measures. The CQC said it will keep the home under review and normally re-inspect within six months if it does not propose cancelling the provider's registration.
Kind staff
People and relatives spoke positively about staff. Inspectors also observed mostly positive interactions.
“People and family members spoke positively about the care provided by staff and told us staff were kind and caring and knew people well.” from the report
Staff training
Staff received training relevant to their roles, along with induction and regular supervision.
“Staff received training relevant to their role and people's needs.” from the report
Health care support
Records showed that people were supported to access health care, and referrals were made when needed.
“Records indicated that people were supported to access health care services and support.” from the report
Cleanliness
The home had cleaning arrangements, suitable protective equipment and infection prevention training.
“Staff were deployed to complete regular cleaning tasks to ensure the home was clean and hygienic.” from the report
Medicines
seriousSome medicines were not given according to prescribing instructions. Records and guidance for creams, patches, thickening powder and hidden medicines were also incomplete or unsafe.
“The provider had failed to ensure that medicines were managed safely. This placed people at risk of avoidable harm.” from the report
Risk management
seriousImportant risks, including falls, blood-thinning medicines and diabetes, were not always recorded or supported with clear guidance. Accidents and incidents were not analysed for patterns.
“The provider had failed to ensure that risk to people's health, safety and wellbeing had been appropriately documented and managed effectively.” from the report
Staffing levels
seriousThere were times when staffing numbers and deployment were not enough to support people safely. People said they sometimes waited a long time for help.
“The provider had failed to ensure there were enough staff deployed to support people safely.” from the report
Management oversight
seriousThe home's audits and checks had not found several important problems. Inspectors found that leadership did not understand some safety and regulatory requirements.
“Governance systems had failed to identify issues and drive necessary improvements to the service.” from the report
Consent records
needs fixingCapacity assessments did not clearly record their outcomes, and there was no evidence of best-interest decisions when people lacked capacity.
“Where people had been assessed as not having capacity to make specific decisions, there was no evidence of a best interests decision being completed.” from the report
Dementia-friendly environment
needs fixingLoud noises created a chaotic atmosphere in the main lounge. Inspectors were concerned this could increase anxiety and distressed behaviour.
“Loud noises from various sources in the main communal lounge area created a chaotic atmosphere.” from the report
- 01What has been changed to make sure medicines are given exactly as prescribed, including hidden medicines, creams, patches and thickening powder?
- 02How are risks such as falls, blood-thinning medicines and high or low blood glucose now recorded and managed?
- 03How many staff are on duty at the times when incidents previously happened most often, and how do you check that people receive help promptly?
- 04What evidence can you show that capacity assessments and best-interest decisions now follow the required process?
- 05What action has been taken to reduce loud noise and make the communal areas more suitable for people living with dementia?
This was a focused inspection of Safe, Well-led and, after further concerns were found, Effective; Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 10 February 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 2022
Rosevilla Residential Home was rated Good; inspectors found safe, caring support, but COVID testing arrangements did not consistently follow guidance.
This was an unannounced focused inspection on 16 December 2021. Inspectors spoke with people living at the home, staff and relatives. They observed care, checked the premises and reviewed care, medicines, staffing and management records.
The home was rated Good overall. Safe and well-led were both rated Good. People said they felt safe and were happy with their care. Inspectors found that risks, medicines, staffing, safeguarding and accidents were generally managed well.
There was one important shortfall in infection control. Staff were not consistently using PCR tests in line with government guidance. The provider acted quickly during the inspection and introduced a new system for recording and monitoring COVID testing.
This inspection only assessed Safe and Well-led. Caring, Effective and Responsive were not inspected during this visit, so their previous ratings were carried forward from the last comprehensive inspection.
Kind and attentive care
People said they were happy and felt safe. Inspectors saw staff supporting people calmly, respectfully and with dignity.
“Staff were attentive and caring with people and supporting them when they became distressed.” from the report
Risks were managed
Care records and risk assessments were kept up to date. Changes to communal areas helped reduce falls.
“Analysis showed that falls had reduced at the home since these changes had been made.” from the report
Safe medicines practice
Medicines were ordered, stored, given and disposed of safely. Staff had training and regular checks of their competence.
“Medication management procedures were in place and medicines were routinely ordered, safely stored, administered and disposed of in accordance with current guidance.” from the report
Good partnership working
The home worked with healthcare professionals and made referrals to support people's health and care needs.
“Joint working with external health and social care professionals meant people had coordinated care.” from the report
COVID testing did not follow guidance consistently
needs fixingStaff were not consistently using PCR tests in line with government guidance. The provider introduced a new recording and monitoring system during the inspection, but families should check that this remains effective.
“However, staff were not consistently using polymerase chain reaction (PCR) in line with government guidance.” from the report
Quality checks missed an infection control issue
needs fixingThe home's governance systems did not identify the PCR testing problem before inspectors found it. The issue was acted on immediately.
“The provider had failed to identify one issue we found in relation to IPC practices and PCR testing in line with government guidance.” from the report
Staff shortages caused some pressure
minorStaff described shortages and recent changes that created strain, although they felt able to cope as a team and inspectors found staffing levels met people's needs.
“Staff told us about staff shortages and recent changes. They discussed strains this created but they felt confident they could cope as a team.” from the report
- 01What new system is now used to record and monitor COVID testing, and how is it checked?
- 02How do you make sure staff PCR testing follows current guidance?
- 03How do you cover shifts when there are staff shortages, and how often do you use agency staff?
- 04What changes were made to the dining room and communal areas after the previous falls, and are falls still being monitored?
- 05What were the previous ratings for Caring, Effective and Responsive, and when will these areas next be reviewed?
This was an unannounced focused inspection of Safe and Well-led only; Caring, Effective and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 8 January 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 Residential Home
5 rated inspections over 9 years: the service has slipped, from Good to Inadequate.
- February 2024Inadequatecurrent ratingdown from GoodSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Inadequate
- January 2022GoodSafe: GoodWell-led: Good
- November 2020Inspected but not ratedSafe: Inspected but not rated
- October 2017Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- June 2016Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- March 2012
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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