CQC report explained · a residential care home
What the CQC found at Rosewood Care 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
- Risk assessments and care plans did not always give staff clear instructions. Inspectors also found discrepancies in medicines balances, although safeguarding and infection control arrangements were in place.
- Effective?
- Requires improvement
- Staff had training and people could access healthcare, but mealtimes lacked interaction and records did not always show how consent and best-interest decisions were managed.
- Caring?
- Good
- People said staff listened to them and treated them with respect. Inspectors saw staff protecting people's dignity and supporting choice and independence.
- Responsive?
- Good
- Staff knew people well and generally met their needs. Care plans and personalised information were still being developed, and activities could be improved for people living with dementia.
- Well-led?
- Requires improvement
- Management changes and the effect of COVID-19 meant improvements were not sustained. Audits existed, but they did not identify all gaps in records, risk information and person-centred care.
What inspectors found, July 2021
Rated Requires Improvement; inspectors found kind and responsive care, but continuing risks, medicines and management problems could put people at risk.
This was a planned, unannounced inspection. Inspectors visited on 29 April 2021 and reviewed records and medicines, spoke with people, relatives and staff, and sought further information after the visit. They also checked infection prevention and control arrangements during COVID-19.
The home had enough staff for people's assessed needs, and inspectors found people were treated with kindness, dignity and respect. People had access to healthcare, activities and contact with relatives. Infection control arrangements were considered satisfactory.
However, risk information was not always clear or complete. Inspectors found gaps in care plans, repositioning records and medicines records. They also found limited interaction during meals and inconsistent person-centred care, including missed opportunities for people living with dementia.
The overall rating remained Requires Improvement. Safe, Effective and Well-led were rated Requires Improvement, while Caring and Responsive improved to Good. The home had held Requires Improvement for four consecutive inspections, and the provider remained in breach of two regulations.
Kind and respectful care
People and relatives described staff as respectful and supportive. Inspectors saw staff protecting privacy and dignity and encouraging independence.
“We saw staff maintained peoples dignity by asking them discreetly if they wanted to use the toilet.” from the report
People's choices
People who were able to do so were involved in daily decisions about their care. Staff listened to people and relatives.
“People who were able told us they were involved in making daily decisions about their care.” from the report
Healthcare support
People could access healthcare services when needed. A visiting healthcare professional said staff followed healthcare recommendations.
“People and relatives confirmed they had access to healthcare services when needed which included opticians and dentist.” from the report
Infection control
Inspectors were assured that the home had arrangements for preventing and managing infection, including use of protective equipment and facilitating visits.
“We were assured that the provider was using PPE effectively and safely.” from the report
Activities and family contact
The home supported contact with relatives during COVID-19 restrictions and offered activities such as games, gardening and themed food sessions.
“The staff have tried their best to make sure we still had some contact with [person] which I am very grateful for.” from the report
Risk information was not reliable
seriousCare plans and risk assessments did not always explain how staff should support people consistently. This included moving and handling, skin care, repositioning and food intake.
“The lack of information meant staff did not have clear consistent guidance on how to support people.” from the report
Medicines records had discrepancies
seriousThe balances of boxed medicines for three people did not match the medicines recorded as administered. This meant the provider could not be sure medicines had been given as required.
“We found discrepancies with the balance of boxed medicines for three people based on what medicines had been administered.” from the report
Limited interaction at mealtimes
needs fixingInspectors saw people mostly eating in silence, with little staff interaction, particularly when staff were helping people eat.
“There was a lack of staff interaction with people particularly where staff were supporting people to eat a meal.” from the report
Management checks missed problems
seriousAudits and monitoring systems were in place, but they did not identify all missing information or ensure improvements were sustained. The provider remained in breach of good governance requirements.
“The systems had not identified all the gaps in records, and monitoring charts.” from the report
- 01What changes have been made to risk assessments and care plans for moving, skin care, repositioning and eating or drinking?
- 02How do you now check that medicines balances and administration records are accurate?
- 03How do staff provide meaningful activities and engagement for people living with dementia?
- 04How are people and their relatives involved in reviewing care plans and recording their preferences?
- 05What action has been taken to meet the continued conditions on the provider's registration?
This was a planned, unannounced inspection covering all five key questions and infection prevention and control; it also followed up concerns and conditions from the previous inspection. This explanation was written from the published report of 7 July 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.
What inspectors found, July 2019
Requires Improvement; inspectors found widespread shortfalls in safety, care planning, staffing oversight and management, with enforcement action taken.
This was an unannounced inspection on 10 and 11 January 2019. One inspector and an expert by experience spoke with people, relatives, staff and health professionals. They observed care, checked care plans and medicines, and reviewed training, incidents, complaints and management records.
The home did some things well. People generally received their medicines as prescribed, staff followed infection control guidance, people could access healthcare, and many people spoke positively about individual staff. People were supported with meals, activities, religious beliefs and visits from relatives.
However, people did not always receive safe or personalised care. Risk assessments and care plans were incomplete or out of date. Records about food, fluids, pressure care and healthcare were not reliable. Safeguarding procedures and required notifications had not always been followed. Quality checks were not effective, and all five areas were rated Requires Improvement.
The home had also been rated Requires Improvement at the May 2017 inspection. The report says the service had not made sustainable improvements and had deteriorated. The CQC took enforcement action and said it would meet the provider and re-inspect.
Kind staff
People and relatives gave positive feedback about individual staff. Inspectors saw people being supported with upset and treated with respect.
“A caring and compassionate staff team supported people.” from the report
Food and drink support
People said they had enough to eat and drink. Inspectors saw appetising food, help being given when needed, and staff awareness of preferences and special diets.
“We saw the food looked appetising and assistance was provided to people where necessary.” from the report
Healthcare access
People said they could see healthcare professionals when needed. A healthcare professional said staff acted on recommendations.
“People told us they had the opportunity to see healthcare professionals such as their GP and optician” from the report
Activities and relationships
People took part in activities they enjoyed, and relatives could visit at any time. Staff knew people's preferences, likes and dislikes.
“People took part in activities that they enjoyed, found interesting and stimulating.” from the report
Infection control
Inspectors found the home clean and tidy. Staff used infection control practices and had protective equipment available.
“The staff followed effective infection prevention and control practice.” from the report
Incomplete risk information
seriousSome people did not have the risk assessments or care plans staff needed to provide safe support. Records and staff knowledge were sometimes unclear or conflicting.
“Not all people had assessments of risk associated with their care.” from the report
Safeguarding and notifications
seriousTwo safeguarding incidents had not followed the correct process, including one that was not referred to the local authority. Six events that should have been notified to the CQC had not been reported.
“People were not consistently protected from the risk of abuse.” from the report
Weak care records
needs fixingCare plans and records about nutrition, hydration, pressure care and healthcare were incomplete or not kept up to date. This meant staff did not always have clear information about people's needs.
“The care and support plans in place did not always reflect people's current or changing needs.” from the report
Staffing and training
needs fixingAgency staff were being used during vacancies, and some people, relatives and staff thought staffing levels needed to increase. Refresher training and competency checks were not complete.
“The provider did not have a system to formally calculate the number of staff required based on current best practice.” from the report
Ineffective management checks
seriousThe home's audits did not identify or address repeated problems. There was no formal development plan showing a planned approach to improvement.
“There were insufficient and inadequate systems in place to monitor and improve the quality of the service.” from the report
Care involvement and end of life wishes
needs fixingPeople and relatives could not recall being involved in care reviews. End of life plans existed but needed more detail so people's wishes could be understood and followed.
“Relatives and people could not recall being involved in reviews of their care.” from the report
- 01What has changed in the new care planning system, and how do you check that care plans and risk assessments reflect each person's current needs?
- 02How do you calculate staffing levels when people's dependency needs change, and how often is this reviewed?
- 03How do you make sure safeguarding incidents and other events are reported to the local authority and the CQC within the required timescales?
- 04How do you check that staff have completed refresher training and are competent to provide the care they are expected to give?
- 05How are residents and relatives now involved in care reviews and in decisions about end of life wishes?
This was an unannounced inspection of the overall service, including all five CQC questions, care provided and the premises. This explanation was written from the published report of 11 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 Rosewood Care Home
5 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- July 2021Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2017Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2016Requires improvementstayed Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2014
Report published without a new overall rating.
- June 2013
Registered with the Care Quality Commission on 18 June 2013.
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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