CQC report explained · a residential care home
What the CQC found at Roslyn House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People's medicines, safeguarding arrangements, fire safety and emergency plans had improved. However, seizure records were incomplete, staff training on supporting people when anxious was unfinished, and risks linked to a full-sized kettle had not been specifically assessed.
- Effective?
- Requires improvement
- This focused inspection did not cover the Effective key question.
- Caring?
- Good
- People were treated with dignity and respect, involved in decisions, and supported to become more independent. Staff listened to people's wishes and respected decisions to decline or change planned support.
- Responsive?
- Good
- Care plans had been improved and people were supported with activities, community visits and relationships. Concerns were investigated, but people were not always given feedback about what action had been taken.
- Well-led?
- Requires improvement
- The deputy manager provided effective day-to-day leadership and the culture had improved. However, governance systems had not ensured that staff had the right skills or that care records were accurate and complete.
What inspectors found, June 2023
Rated Requires Improvement; inspectors found much kinder and safer care, but incomplete records and staff training gaps remain, and the home is no longer in special measures.
This was an unannounced focused inspection on 09 May 2023. One inspector visited, spoke with both people living there, staff, managers, a relative and health and social care professionals. Records, medicines, care plans, risk assessments and quality checks were also reviewed.
There had been significant improvement since the previous inspection, which rated the service Inadequate. People were treated with dignity, medicines were managed safely, complaints were investigated, and people were supported to go out and take part in activities.
The service was still not fully safe or well-led. Seizure monitoring records were incomplete, some staff had not received needed training, and quality checks had not found these problems. The overall Requires Improvement rating means improvements were made, but there was still limited assurance about safety and the service was not consistently well managed.
Safer medicines
Medicines were given as prescribed. The records and storage arrangements had improved, including checks for as-required medicines and storage temperatures.
“People had been safely supported with their medicines. Medication administration record (MAR) charts were fully completed and demonstrated people had received their medicines as prescribed.” from the report
Dignity and choice
People were comfortable with staff and were treated respectfully. Their preferences, privacy and decisions to change or decline support were respected.
“Staff respected people's privacy and dignity. Where people had expressed preferences in relation to how support was provided these wishes were respected.” from the report
Community activities
People were supported to go out regularly and take part in activities they enjoyed, including community events and lunch visits.
“People were supported to access the community regularly and both people went out for lunch on the day of the inspection.” from the report
Incomplete seizure records
seriousRecords were not completed for all seizures. This made it harder for health professionals and staff to understand the person's needs and possible causes.
“Monitoring records introduced to enable health professionals to fully understand one person's experiences before and after they experienced seizures had not been completed in respect of all seizures that had occurred.” from the report
Staff training still unfinished
needs fixingThe provider had identified a need for practical training to support people when anxious or upset, but this had not yet been arranged.
“The provider recognised the need for staff to receive practical training in the use appropriate techniques to meet people's support needs at times when they became upset or anxious.” from the report
Risk assessment for kettle
needs fixingA person at significant risk when using a kettle had their own full-sized kettle, but the specific risks had not been assessed and no control measure had been identified.
“The risks associated with this kettle had not been specifically assessed and the staff were unaware the kettle was full-sized.” from the report
Weak quality checks
seriousThe provider had introduced new quality checks, but these had not prevented incomplete care records. This led to an ongoing breach of governance requirements.
“The provider's systems had failed to ensure staff had the skills necessary to meet people's needs and that care records were accurately completed.” from the report
Limited complaints feedback
minorConcerns were investigated and discussed with staff, but the person who raised a concern was not given formal feedback about the action taken.
“However, no formal feedback was provided to the person who had raised the concern detailing the actions taken by the provider.” from the report
- 01What practical training has now been completed to support people when they become anxious or upset?
- 02How are seizure records checked after every event, and who reviews them for missing information?
- 03What specific risk assessment and safety measures are now in place for the full-sized kettle?
- 04How will you check that care records are complete and accurate every day?
- 05How will people who raise concerns be told what action has been taken?
This was a focused inspection of Safe, Caring, Responsive and Well-led only; the Effective key question was not covered. This explanation was written from the published report of 6 June 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, May 2023
Roslyn House rated Inadequate and was placed in special measures; inspectors found widespread failures in safety, dignity, personalised care and leadership.
This was the first inspection since the home registered in November 2022. It was an unannounced comprehensive inspection on 23 and 26 February 2023. Inspectors spoke with people, staff, a relative and health and social care professionals. They also checked care plans, risk assessments, medicines records, staff records and quality audits.
Inspectors found people were at risk of avoidable harm. Medicines records had gaps, staff lacked important training, and guidance for supporting people during anxiety or distress was not sufficient. Staffing arrangements often meant people could not get support to go out into the community.
People were not always treated with dignity or respect. Care plans were too brief and did not explain people's needs, goals or preferences well enough. The provider's checks and leadership systems were ineffective, and required notifications had not always been made.
The overall rating and four of the five key questions were Inadequate. Effective was rated Requires Improvement. The home was placed in special measures, meaning the CQC will monitor it and normally re-inspect within six months unless it proposes to cancel the provider's registration.
Building safety
Firefighting equipment and the home's utilities had been checked regularly.
“Firefighting equipment and the services utilities had been regularly checked to ensure they were operating safely.” from the report
Access to healthcare
Staff worked with health professionals and supported people to access healthcare when needed.
“Staff worked with health care professionals to ensure people's needs were met.” from the report
Some responsive support
People could approach staff for help, and staff responded promptly when they thought support was needed.
“People were confident approaching staff for support and did so without hesitation.” from the report
Visits welcomed
The home encouraged relatives and friends to visit, with no visiting restrictions in place.
“The service encouraged people friends and relatives to visit and there were no visiting restrictions in place.” from the report
Risk and medicines failures
seriousRisks linked to anxiety, distress and seizures were not recorded or managed properly. Medicines records had gaps and staff did not always have the guidance needed.
“People's medicines were not managed safely. Medication administration record (MAR) charts had not been accurately completed and included gaps.” from the report
Lack of dignity and respect
seriousInspectors heard disrespectful language in records and conversations. A person's withdrawal of consent was not respected.
“The provider and staff team did not consistently respect people's privacy and dignity.” from the report
Staff skills and supervision
seriousMost staff had not completed all training the provider considered necessary, and care staff had not received supervision since the home opened.
“The staff team did not have the skills necessary to meet people's care needs” from the report
Limited community support
needs fixingThe staffing rota meant people were usually unable to get staff support to go out. Activities often did not match their interests or needs.
“Current staffing arrangements meant it was unusual for people to be supported while accessing the community.” from the report
Weak care planning
needs fixingCare plans lacked useful detail about people's needs, life histories, goals and aspirations. This made personalised support harder to provide.
“People's care plans did not provide sufficient detailed guidance to enable staff to provide person centred care.” from the report
Ineffective governance
seriousQuality audits were not completed effectively, complaints were not formally investigated, and required notifications had not been submitted.
“The provider governance systems were ineffective and had failed to ensure the service consistently complied with the requirements of the regulations.” from the report
- 01What has been done to correct the gaps and unsigned entries in medicines administration records?
- 02What training have all staff now completed for supporting people who become anxious or distressed?
- 03How will the current staffing rota ensure people can be supported safely to access the community?
- 04How have care plans been improved to include each person's needs, goals, life history and preferred activities?
- 05What audits and complaint records are now in place, and how are required notifications being made?
This was an unannounced comprehensive inspection of the newly registered care home and covered all five key questions. This explanation was written from the published report of 6 May 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.
Every inspection of Roslyn House
2 rated inspections over a year: the service has improved, from Inadequate to Requires improvement.
- June 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2023InadequateSafe: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- November 2022
Registered with the Care Quality Commission on 11 November 2022.
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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Most charge £980 to £1,200 a week. 8 can care for a couple. 12 years' experience on average.
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