CQC report explained · a nursing home
What the CQC found at Rushall Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, September 2023
Rushall Care Home is rated Good; inspectors found safe care and stronger management, with a minor medicines stock-check issue.
This was an unannounced focused inspection on 2 August 2023. One inspector and an Expert by Experience spoke with people, visitors and staff, observed care, and checked records including recruitment files, policies and audits.
The home was rated Good overall. Inspectors found people were safe, medicines were generally given as prescribed, there were enough staff, and infection controls were in place. People and relatives spoke positively about the care and management.
The Safe and Well-led ratings improved from Requires Improvement at the previous inspection. The provider was no longer in breach of Regulations 12 and 17. The other three areas were not inspected during this visit, so their previous ratings were used in calculating the overall rating.
People felt safe
People and relatives said they felt safe. Inspectors found that risks were assessed, care plans were updated and staff knew how to report abuse.
“People felt safe living at the home and relatives confirmed there were no safety concerns.” from the report
Enough staff
People, relatives and staff said staffing levels were enough. Inspectors saw that people did not have to wait for their care needs.
“We saw people did not have to wait for their care needs to be met and staff had time to spend with people.” from the report
Medicines improvements
The report says medicines were now administered safely, with trained and assessed nurses, accurate administration records and safe storage.
“At this inspection the provider had made the required improvements.” from the report
Management oversight
The manager used audits and action plans to identify and address improvements. Feedback from people, relatives, staff and visitors was collected.
“The registered manager used a range of audit tools to ensure people received good quality care.” from the report
Some medicines stock counts were wrong
needs fixingThe electronic medicines system did not consistently adjust stock levels, and some counts were incorrect during the inspection. The manager corrected the stock and introduced an extra check, while the report says people had received their medicines as prescribed.
“On inspection some of the stock counts we completed were not correct.” from the report
- 01What extra check is now used to make sure electronic medicines stock levels are correct?
- 02How do you check that people's risk assessments and care plans stay up to date after a change in health or an incident?
- 03What improvements to the home environment and décor have been completed since this inspection?
- 04How are people's meal preferences, culture, religion and other personal choices reflected in their care?
- 05What were the previous ratings for Effective, Caring and Responsive, which were not inspected during this visit?
This was a focused inspection of Safe and Well-led only; the other three key-question ratings were carried over from the previous inspection when calculating the overall rating. This explanation was written from the published report of 15 September 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, October 2022
Rushall Care Home is rated Requires Improvement; inspectors found serious gaps in pressure care and management oversight, and issued warning notices.
This was an unannounced focused inspection on 28 June 2022. Inspectors looked only at Safe and Well-led because they had received concerns about pressure care, repositioning records, weight loss, management and safeguarding. They spoke with people, relatives, staff and visiting health professionals, and checked care records, medicines, staff files and management records.
The home was not always keeping people safe. Some people were not repositioned as often as their care plans said, including one gap of 11 hours and 31 minutes. This increased the risk of pressure wounds getting worse. Medicines were not always stored or dated safely, although the manager took immediate action on the issues found.
Management checks did not reliably identify these problems or learn from them. The home was rated Requires Improvement for Safe and Well-led, and the overall rating remained Requires Improvement. This was the second consecutive inspection with that overall rating.
Staffing and recruitment
Inspectors found safe recruitment processes, induction for new staff and enough care staff on duty to meet people's needs.
“We found the provider had robust recruitment processes which promoted people's safety.” from the report
Safeguarding
People said they felt safe. Staff understood how to recognise abuse and how to report concerns.
“The provider had clear safeguarding and whistleblowing systems in place which staff knew how to effectively use.” from the report
Infection control
Inspectors were assured that infection prevention measures, protective equipment, testing and visiting arrangements followed current guidance.
“We were assured that the provider was using PPE effectively and safely.” from the report
Involvement and staff culture
People and relatives were invited to share their views through meetings and surveys. Staff said they could raise concerns with the manager.
“We found the staff and registered manager involved people in their care.” from the report
Pressure care and repositioning
seriousPeople with pressure care needs were not always repositioned at the times set out in their care plans. Inspectors found one interval lasting 11 hours and 31 minutes, creating a risk of further skin damage.
“The provider failed to ensure risks to people's safety were effectively managed exposing them to harm.” from the report
Weak management checks
seriousThe home's monitoring systems did not identify missed repositioning, conflicting guidance or medicine management problems. This was a continued breach of regulation 17.
“The provider failed to implement robust systems to monitor and improve the quality of the service.” from the report
Medicine safety
needs fixingInspectors found an out-of-date opened medicine, medicines that had not been dated when opened, and a medicine competency check that was overdue. The manager took action during the inspection.
“People's medicines were not always stored safely.” from the report
Unreported maintenance risks
needs fixingBroken safety glass and sharp broken plastic had not been reported by staff. The manager acted immediately to address these concerns.
“Maintenance concerns from environmental risks were not always reported by staff.” from the report
- 01How are you now checking that each person is repositioned at the interval in their care plan?
- 02What evidence can you show that the Warning Notice about pressure wound deterioration has been addressed?
- 03How do you make sure care plans and risk assessments give staff consistent repositioning instructions?
- 04How are medicines dated, stored and checked after opening, and how often are staff medicine competencies assessed?
- 05What changes have been made to management audits and incident reviews since this inspection?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous inspection. This explanation was written from the published report of 25 October 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 Rushall Care Home
5 rated inspections over 8 years: the service has held its Good rating throughout.
- September 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- February 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- December 2018Goodstayed GoodSafe: GoodWell-led: Good
- October 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2015
Registered with the Care Quality Commission on 1 April 2015.
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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At least 100 live-in carers within about an hour of Walsall
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £950 to £1,200 a week. 85 can care for a couple. 9 years' experience on average.
“I have never met a person who is so kind and thinks about others before himself to such an extent as Chris Malagala.”
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