CQC report explained · a residential care home
What the CQC found at Roughcote Hall Farm
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found people were protected from abuse and avoidable harm. Medicines, staffing, recruitment, risk assessments and infection control were managed safely.
- Effective?
- Good
- This key question was not inspected in this focused report.
- Caring?
- Good
- This key question was not inspected in this focused report.
- Responsive?
- Good
- This key question was not inspected in this focused report.
- Well-led?
- Good
- Inspectors found effective quality checks, learning from incidents and good involvement of people, relatives and professionals. A recommendation was made about checking window restrictors against current safety advice.
What inspectors found, March 2023
Rated Good; inspectors found safe, person-centred care and improvements since the previous inspection, but window restrictors still needed checking.
This was an unannounced focused inspection. An inspector visited the home and an Expert by Experience contacted relatives. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicines, recruitment and management records.
The home was rated Good overall. Safe and Well-led were both rated Good. Inspectors found enough safely recruited staff, safe medicines systems, regular risk reviews and suitable infection control. People said they felt safe and staff knew their needs and preferences.
The previous inspection rated the home Requires Improvement in August 2021. Inspectors found the required improvements had been made in medicines, agency staff records and quality checks. They recommended that the home seek advice and fully check that window restrictors meet current safety advice.
Safe medicines
Medicines were stored securely, stock was checked and administration records were accurate. Improvements had been made since the last inspection.
“Medicines administration records were accurately completed and there was guidance in place for staff about how to administer medicines.” from the report
Enough suitable staff
Inspectors found enough staff to meet people's needs. Recruitment checks were completed, including checks on past employment and through the Disclosure and Barring Service.
“There were enough safely recruited staff to support people.” from the report
Personalised support
People were involved in planning their care, setting goals and choosing activities. Staff supported communication, sensory needs, interests and contact with family.
“People received person centred care and had their needs and preferences met by staff who knew them well.” from the report
Learning and improvement
The manager used audits and reviews to identify changes needed. Incidents were reviewed and learning was shared with staff.
“Where incidents and accidents happened risk assessments and care plans were reviewed, and changes made to prevent reoccurrence, wider learning was considered and shared with staff.” from the report
Window restrictors
needs fixingSome additional window restrictors had been fitted, but the provider had not yet fully checked that all restrictors met current safety advice. CQC made a recommendation and said it would check this at the next inspection.
“We recommend the provider seeks advice from a reputable source about the provision of suitable window restrictors and ensures these are fitted, we will check this at our next inspection.” from the report
- 01Have all window restrictors now been checked, and what reputable safety advice was used?
- 02How are medicines stock levels and administration records checked now?
- 03How do people take part in reviewing their care plans and choosing their activities?
- 04How are incidents reviewed and changes shared with staff?
- 05Which ratings from the previous comprehensive inspection apply to Effective, Caring and Responsive?
This was an unannounced focused inspection of Safe and Well-led; the other key question ratings were not inspected in this report and were carried over from the last comprehensive inspection. This explanation was written from the published report of 9 March 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, August 2021
Rated Requires Improvement; inspectors found people felt safe and happy, but medicines and management systems were not always reliable.
This was an unannounced focused inspection after concerns about management and support when people became upset. The inspector visited on 10 and 30 June 2021, spoke with people, staff and relatives, observed the home and checked care, medicine, recruitment and management records.
People generally felt safe and happy. There were enough staff, but the home relied on agency workers while permanent recruitment continued. Medicines were not always properly accounted for, and one person's support plan had not been developed with the relevant professional. Infection testing records for agency staff and the infection control policy also needed improvement.
Management and quality checks were not yet reliable. A new registered manager had started at the end of March 2021 and was making changes, but care plans, audits and other checks were still being updated. The overall rating changed from Good at the previous inspection to Requires Improvement. Only Safe and Well-led were inspected at this visit.
People felt safe and respected
People and relatives said people felt safe. Inspectors also found that people were supported with dignity and encouraged to be as independent as possible.
“People were supported to be as independent as possible. People were supported with dignity.” from the report
Enough staff on duty
People did not have to wait for support, and people and staff said staffing levels were sufficient at the time of inspection.
“One person said, "I feel there are enough staff." People did not have to wait for support and staff told us they felt there were enough staff.” from the report
Safeguarding awareness
Staff understood different types of abuse and knew they had to report concerns. Safeguarding referrals were made when concerns were identified.
“Staff understood their safeguarding responsibilities. They knew of different types of abuse, how to recognise this and their responsibility to report these.” from the report
Learning from incidents
Accidents and incidents were reviewed for patterns, and actions were recorded to reduce the chance of problems happening again.
“Accidents and incidents were recorded and analysed to look for trends and action taken to reduce the ongoing risk of repeat occurrences was documented.” from the report
Approachable new manager
People, relatives and staff spoke positively about the new registered manager. Staff felt supported and able to raise concerns or suggest improvements.
“People, relatives and staff all felt positively about the registered manager and felt they were approachable.” from the report
Medicine records did not match stock
seriousSome medicine stock levels did not match the records, and there was no explanation for some differences. Inspectors found no evidence that anyone had been harmed, but could not always be sure people received medicines as prescribed.
“Some stock levels of medicines were not correct when compared to records and there was no explanation for some of these stock differences.” from the report
Management checks were not reliable
needs fixingQuality assurance systems, compliance checks and medicine audits had not been fully or consistently completed. This meant some problems had not been identified promptly.
“Quality assurance systems were not fully embedded and some improvements needed had not yet been identified.” from the report
Reliance on agency staff
needs fixingThere had been high turnover among managers and staff, and the home relied on agency workers while recruiting permanent staff. Staff and relatives said more permanent staff would help people build stronger relationships and adjust more easily.
“There had been a high turnover of management and staff, so there was a reliance on agency staff, but recruitment was ongoing, although a registered manager had now started.” from the report
Infection records and policy needed updating
minorRecording of COVID-19 tests for agency staff was not robust, and the infection control policy did not include current COVID-19 guidance. Inspectors said the guidance itself was being followed.
“The provider had been less robust with the recording of agency staff tests.” from the report
- 01What checks are now used to make sure medicine stock matches the records every time?
- 02Have all unexplained medicine discrepancies been investigated and resolved?
- 03Are all care plans and risk assessments now complete, including professional input where needed?
- 04How many permanent staff are currently employed, and how is the use of agency staff being reduced?
- 05How are agency staff COVID-19 tests and infection control responsibilities recorded now?
This was a focused inspection of Safe and Well-led only; the other key questions were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 6 August 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 Roughcote Hall Farm
3 rated inspections over 4 years: the service has held its Good rating throughout.
- March 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- March 2019GoodSafe: GoodWell-led: Good
- September 2017
Registered with the Care Quality Commission on 15 September 2017.
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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