CQC report explained · a nursing home
What the CQC found at Roseworth Lodge Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks, medicines, staffing, fire safety and infection control were managed safely. They found the home was no longer in breach of Regulation 12.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its rating was carried forward from the previous inspection, although inspectors did observe kind and respectful support.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Well-led?
- Good
- Inspectors found that new quality checks, management arrangements and electronic records were established. The home was no longer in breach of Regulation 17.
What inspectors found, July 2023
Rated Good after improvements from Inadequate; inspectors found a safer, better-managed home, but this was a focused inspection.
Inspectors visited without notice on 19 and 26 June 2023. They spoke with people living at the home, relatives, staff and a visiting healthcare professional. They also reviewed documents about safety and management.
The home was rated Good for Safe and Well-led. Inspectors found that risks were managed, medicines and infection control were safer, staffing was sufficient, and fire arrangements had improved. The environment had been repaired and adapted to help people living with dementia.
The home had previously been rated Inadequate and had been in Special Measures since December 2022. Inspectors found that the earlier legal breaches had been addressed. The home was no longer Inadequate or in Special Measures.
Safer environment
Repairs, replacement furniture and equipment, improved lighting and dementia-friendly signs made the environment safer and easier to use.
“The provider had made extensive improvements to the environment. Equipment and furniture had been replaced and repairs had been completed.” from the report
Fire and emergency planning
Fire arrangements had improved. Emergency evacuation plans were accurate, a new alarm system was installed and fire drills exceeded the required number.
“A new fire alarm system had been installed and fire drills exceeded the required number needed.” from the report
Better care records
A new electronic system gave managers current information about people's care, including fluid intake and output, so they could respond more quickly.
“This enabled staff to record accurate information including fluid intake and output, this enabled the management team to view current information and take quicker action.” from the report
Kind and respectful support
Inspectors saw staff speak warmly to people, seek permission before providing support and offer reassurance when people were distressed.
“Staff were kind and caring. Staff had completed dignity and respect training.” from the report
Stronger management checks
New quality assurance systems were fully established, with additional roles supporting the management team and better oversight of clinical information.
“New quality assurance systems had been developed and were fully established.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you check that the new electronic care records remain accurate and up to date?
- 02How are my relative's individual risks reviewed and changed when their needs change?
- 03What checks are now carried out to make sure the improvements to the building, equipment and infection control are maintained?
- 04How will you keep families informed about feedback, complaints and any further improvements?
- 05What were the ratings for Effective, Caring and Responsive at the previous inspection, and when will these areas be reviewed again?
This was an unannounced focused inspection of Safe and Well-led, including infection prevention and control; the other key-question ratings were carried forward from the previous inspection. This explanation was written from the published report of 14 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, December 2022
Rated Inadequate and placed in special measures; inspectors found serious problems with safety, dignity and management.
This was an unannounced focused inspection after concerns about catheter and diabetes care. Inspectors visited on 2 and 4 November 2022, spoke with people, relatives and staff, and checked care, medicines and management records.
The home was rated Inadequate for Safe and Well-led. Inspectors found incomplete monitoring of blood glucose and catheter care, unsafe environmental conditions, weak infection control, poor fire evacuation planning and staffing that was not always enough to meet people's needs.
People were not always treated with dignity and respect. Care records were incomplete and not securely stored. Quality checks were ineffective, so managers had not identified or corrected important risks.
The overall rating fell from Good at the previous inspection, published on 28 April 2021. The home was placed in special measures, and the provider was required to submit an action plan while CQC and the local authority monitor progress.
Recruitment checks
The provider carried out checks before employing new staff, including criminal-record checks and references.
“The provider conducted checks including Disclosure and Barring Service checks and obtained references before new staff were employed.” from the report
Safeguarding process
The home had systems to investigate safeguarding concerns, and staff had completed safeguarding training.
“Safeguarding concerns were investigated and reported to the appropriate authorities.” from the report
Mental capacity practice
Inspectors found that the service was working within the principles of the Mental Capacity Act and had legal authorisations where needed.
“The service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.” from the report
Action on medicines
The provider had begun making changes to improve medicines management and was working with the local authority.
“The provider had taken action to improve the management of medicines.” from the report
Clinical monitoring
seriousBlood glucose and catheter input and output records were incomplete. This placed people at risk of harm.
“Recording of blood glucose levels and monitoring of input and output relating to catheter care were not fully completed placing people at risk of harm.” from the report
Fire safety
seriousSome people did not have personal evacuation plans. Fire drills were not regular, and staff were not confident using evacuation equipment.
“Fire drills had not regularly taken place and staff were not confident in the use of evacuation equipment.” from the report
Infection control and repairs
seriousPersonal protective equipment was not always available or disposed of correctly. Some areas and equipment were dirty, damaged or difficult to clean.
“Cleaning rotas were marked as completed; however some areas of the home were not clean and wheelchairs and commodes were dirty and rusty.” from the report
Staffing levels
needs fixingStaffing was not always enough for people's needs. Inspectors saw people unattended and had to find staff to provide support on three occasions.
“On 3 occasions we had to find staff to support people and we observed people unattended without staff present.” from the report
Poor oversight
seriousQuality checks were ineffective, and care records were incomplete, not reviewed and not securely stored.
“The provider did not have effective systems in place to monitor and improve the quality and safety of the service.” from the report
Dignity and respect
seriousStaff did not always recognise when care did not meet people's needs, and people's dignity was not always respected.
“Staff did not support people in an inclusive manner. Staff did not recognise when people's care and treatment did not reflect their needs.” from the report
- 01What changes have you made to record blood glucose levels and catheter input and output, and how do you check these records are complete?
- 02Does every person who needs one now have a current Personal Emergency Evacuation Plan, and how often are fire drills carried out?
- 03How have you improved staffing levels so people are not left unattended when they need support?
- 04What repairs and cleaning work has been completed on wheelchairs, commodes, handrails, bathrooms, mattresses and bedrails?
- 05How do you now check that care plans are complete, follow health professionals' guidance and are stored securely?
This was a focused inspection of Safe and Well-led following concerns about catheter and diabetes care; the other key-question ratings were carried over from the previous inspection. This explanation was written from the published report of 6 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.
Every inspection of Roseworth Lodge Care Home
4 rated inspections over 6 years: the service has held its Good rating throughout.
- July 2023Goodcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2022Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- April 2021Goodstayed GoodSafe: Requires improvementWell-led: Good
- November 2017GoodSafe: GoodWell-led: Good
- October 2016
Registered with the Care Quality Commission on 17 October 2016.
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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