CQC report explained · a residential care home
What the CQC found at Roshini Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Inspectors found potential hazards, including expired food and unsecured cleaning products and sharp knives. The provider acted immediately, but medicines records were not always clear or accurately completed.
- Effective?
- Good
- People's needs and choices were assessed and reviewed. Staff had training and support, and people were helped to access healthcare and develop independent living skills.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff knew people well and involved them in choices about their care and daily lives.
- Responsive?
- Good
- People received personalised care that reflected their needs and preferences. They were supported with activities, relationships, communication and use of the local community.
- Well-led?
- Good
- The home had systems for checking quality and responding to complaints and incidents. People and staff were involved in meetings and felt supported.
What inspectors found, July 2022
Roshini Care Home was rated Good overall; inspectors found kind, personalised care, but safety and medicines records needed improvement.
Inspectors visited without notice on 5 July 2022. They spoke with three people and all staff on duty. They observed care, checked the building and equipment, and reviewed care, medicines, staffing, training, complaints and incident records.
People were described as happy and well cared for. Staff supported personal choices, community activities, family contact and learning skills for more independent living. Inspectors rated Effective, Caring, Responsive and Well-led as Good.
Safe was rated Requires Improvement. Inspectors found expired food, unsecured cleaning products and sharp knives, although the risk was judged minimal and the provider acted immediately. Medicines were given safely, but some medicines records were unclear or incomplete.
Kind and respectful care
People said they were happy and well cared for. Inspectors saw staff treating people kindly and supporting them when they were distressed or confused.
“People told us they were happy and well cared for.” from the report
Personalised support
Care plans reflected people's needs and preferences, and people were involved in reviewing their care and making choices.
“People received personalised care which met their needs and preferences.” from the report
Independence and community life
People were supported to learn new skills, use local shops and leisure facilities, keep in touch with family and work towards more independent settings.
“People were supported to move to more independent settings by learning new skills.” from the report
Supported staff team
Staff had induction, regular training, meetings and individual support. They told inspectors they felt well supported.
“The staff told us they felt well supported and had access to a range of information about their roles and responsibilities as well as training.” from the report
Improvements since the last inspection
The home improved in all four areas previously rated Requires Improvement apart from Safe. The provider was no longer in breach of the regulations identified at the previous inspection.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulations.” from the report
Medicines records
needs fixingPeople received medicines safely and as prescribed, but some records were unclear or not completed accurately. This could increase the risk of errors.
“Some of the records relating to medicines were not clear or always completed accurately.” from the report
Potential hazards
needs fixingInspectors found expired food and cleaning products and sharp knives that were not securely stored. The provider dealt with these immediately, and inspectors said the risk was minimal.
“We identified a number of potential hazards which included food which had expired the use by date, as well as cleaning products and sharp knives which had not been stored securely.” from the report
- 01What changes have been made to ensure medicines records are always clear and completed accurately?
- 02How do you now check for expired food and make sure cleaning products and sharp knives are securely stored?
- 03How will you support my relative to develop independence while managing any risks?
- 04How are people and their families involved in reviewing care plans and raising concerns?
- 05What staffing arrangements are used when there are absences or vacancies?
This was an unannounced inspection covering all five CQC questions, including infection control, the environment, care records, medicines, staffing and management systems. This explanation was written from the published report of 16 July 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.
What inspectors found, July 2021
Roshini Care Home: inspected but not rated; inspectors found repeated breaches involving care plans, consent, risk management and governance.
This was a targeted inspection on 17 November 2020. Inspectors checked whether earlier problems had been fixed, including concerns about personalised care, consent, safety, safeguarding and management. They also looked at infection control.
The home had not made enough improvement in several areas. Risk plans and care plans were not always up to date. Records about incidents, mental capacity and safeguarding were incomplete. Infection control procedures were not always followed.
The service was inspected but not rated because this visit did not cover the full key questions. The previous overall rating was Requires Improvement, published on 25 December 2019, and that rating remained unchanged.
Safeguarding referrals
The home had improved how it reported safeguarding concerns to the local authority. Inspectors found evidence that referrals had been made.
“At this inspection we saw that where a safeguarding concern had been identified it had been reported to the local authority safeguarding team and there were copies of correspondence to evidence this.” from the report
Some safety checks
The home carried out regular fire safety checks and an annual check of its water systems for legionella.
“An annual check was carried out of the water systems to monitor for legionella.” from the report
Incomplete risk plans
seriousSpecific risk plans were not always in place. This meant care workers might not have had enough guidance to reduce risks to people's health and wellbeing.
“Risk management plans were not always in place where a specific risk related to a person's health and wellbeing had been identified.” from the report
Incidents not properly reviewed
seriousSome incidents and accidents were not recorded through the correct process, and follow-up actions were not always documented. This reduced the home's ability to prevent similar events happening again.
“Incident and accident forms were not always completed when an issue was identified.” from the report
Infection control shortfalls
seriousCOVID-19 risk plans were incomplete, social distancing was not followed at a meal, and a care worker was not wearing a mask correctly. Inspectors said this placed people at risk of harm.
“This placed people at risk of harm. This was a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Unclear consent records
seriousMental capacity assessments did not always clearly show whether people could consent to their medicines. There was also no recorded capacity assessment and best-interest decision for some COVID-19 testing.
“This meant in both examples it was not clear if the person did or did not have the ability to consent to their medicines being administered to ensure this met with the principles of the MCA.” from the report
Out-of-date care plans
needs fixingSome care plans did not reflect changes in people's health, support needs or behaviour. Care workers might therefore not have had the information needed to provide suitable support.
“This meant that care workers did not have access to up to date information on how they should support the person.” from the report
Weak quality checks
needs fixingAudits did not always identify inaccurate care plans, recording problems or safeguarding issues. The home also failed to send some required notifications to the CQC.
“Therefore, the provider did not have a quality assurance process in place that was always effective.” from the report
- 01What action has been taken to ensure every person has a current, individual risk management plan?
- 02How are care plans updated after hospital admissions, changes in health or changes in behaviour?
- 03How are mental capacity assessments and best-interest decisions recorded for medicines and COVID-19 testing?
- 04How are incidents and accidents recorded, reviewed and used to prevent them happening again?
- 05What checks now confirm that infection control procedures, including masks and distancing at meals, are being followed?
This was a targeted inspection of specific concerns and earlier breaches, not a full assessment of the five key questions, so all key-question ratings were left as inspected but not rated and the previous Requires Improvement rating carried over. This explanation was written from the published report of 8 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.
Every inspection of Roshini Care Home
2 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- July 2022Goodcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2021Inspected but not ratedSafe: Inspected but not ratedEffective: Inspected but not ratedResponsive: Inspected but not ratedWell-led: Inspected but not rated
- December 2019Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2018
Registered with the Care Quality Commission on 2 August 2018.
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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