CQC report explained · a residential care home
What the CQC found at Rushley House Retirement Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about infection prevention, visiting arrangements, protective equipment, testing and the home's ability to prevent or manage outbreaks.
- Effective?
- Good
- This question was not part of the focused inspection and no rating was given in this report.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. People and relatives said staff were caring, and inspectors observed warm and reassuring interactions.
- Responsive?
- Requires improvement
- Care plans were personalised and regularly updated, but people did not always have access to a range of meaningful activities. The home had been given a further recommendation to improve this.
- Well-led?
- Good
- The home was approachable and person-centred, and people and relatives were positive about its management. However, quality monitoring had not addressed the activities concern effectively.
What inspectors found, March 2022
Rushley House Retirement Home was rated Good overall; inspectors found kind, respectful care, but activities were still limited and Responsive was Requires Improvement.
This was an unannounced, focused inspection on 3 March 2022. Inspectors spoke with people living at the home, relatives, staff and a provider representative. They reviewed care records, management records and the home itself.
People told inspectors they were happy and well cared for. Staff were kind, respectful and knew people well. Care plans had improved and gave staff useful information about people's needs, choices and communication. Infection control arrangements were also thorough.
The main weakness was activities. There was no formal activities programme, and records did not show people's wishes in this area. The home remained Requires Improvement for Responsive. The overall rating rose from Requires Improvement to Good, while Caring and Well-led were rated Good. Safe was inspected but not rated.
Kind and respectful care
Staff were patient, kind and respectful. Inspectors saw friendly conversations and staff offering reassurance and encouragement.
“Staff treated people with care, patience and kindness.” from the report
Improved care records
Care plans were regularly reviewed and updated when people's needs changed. They gave staff guidance about people's needs, preferences and behaviour.
“People's care plans were regularly reviewed and updated when people's needs changed.” from the report
Positive management
People and relatives described the manager as visible, approachable and supportive. The home had a positive, family-like atmosphere.
“People and their relatives told us the registered manager was visible, approachable and supportive.” from the report
Limited activities
needs fixingThere was no formal activities programme and no clear record of people's wishes about activities. This was the second inspection where the home had been asked to improve this area.
“We recommend the provider seeks and records the views of people around activities and what is important to them in this area.” from the report
Variable quality checks
needs fixingThe provider's systems for checking service quality were not always effective. They had not resolved the continuing concern about activities.
“On occasions, the effectiveness of the provider's systems to monitor and oversee the quality of the service could be variable.” from the report
- 01What activities are currently available, and how do you match them to each resident's interests and wishes?
- 02How do you record whether residents are taking part in meaningful activities and stimulation?
- 03What has changed since the inspection to address the repeated concern about activities?
- 04How do you check that your quality monitoring systems identify and resolve problems?
- 05Which parts of care were not reviewed during this focused inspection, and when were they last inspected?
This was a focused inspection of Caring, Responsive and Well-led, with infection control also reviewed under Safe; other key question ratings used for the overall rating came from the previous inspection. This explanation was written from the published report of 30 March 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, October 2020
Rated Requires Improvement; inspectors found good safety, effectiveness and leadership, but raised concerns about COVID-19 precautions.
This was an unannounced focused inspection on 17 and 30 September 2020. One inspector reviewed records, observed care and spoke with people, relatives, staff and a health professional. The inspection also looked at infection control during the COVID-19 pandemic.
The home was rated Good for Safe, Effective and Well-led. Inspectors found enough staff, safe medicines management, suitable safeguarding arrangements and improvements in recruitment, training and care records. People and relatives spoke positively about the care, food and management.
The overall rating remained Requires Improvement. The inspection found that staff were not always told to wear face masks within two metres of people, and there were no risk assessments explaining this decision. Communal areas also did not support social distancing well.
The home had been rated Requires Improvement after the previous inspection, when there were multiple breaches of regulation. Inspectors found that the provider had made enough improvement and was no longer in breach, but the overall rating stayed Requires Improvement because this was a focused inspection and some previous ratings were carried forward.
Improved safety systems
The home had improved its safeguarding, recruitment and risk management arrangements since the previous inspection. Inspectors found that people were safe and protected from avoidable harm.
“This meant people were safe and protected from avoidable harm.” from the report
Safe medicines
Medicines were received, stored, given and disposed of safely. The home had also introduced extra checks on medicine stocks.
“Medicines were received, stored, administered and disposed of safely.” from the report
Enough trained staff
Inspectors found enough staff to meet people's needs. Staff had completed the Care Certificate and said they received ongoing training and support.
“There were enough staff on duty to meet people's needs.” from the report
Good links with health services
The home worked with GPs, district nurses, therapists and other professionals. A visiting health professional said the service was organised and allowed actions to happen quickly.
“A visiting district nurse told us the service was very organised, allowing actions to take place quickly and smoothly.” from the report
Positive relationships
People and relatives gave positive feedback about staff and management. Inspectors observed people being involved in decisions about their support.
“We observed people making decisions on the support they received throughout our visit.” from the report
Face mask guidance
needs fixingInspectors were not assured that personal protective equipment was being used safely and effectively. Staff had not been instructed to wear face masks when within two metres of people, and there was no risk assessment explaining this.
“The registered manager had not followed all good practice guidance in relation to Covid-19.” from the report
Poor social distancing
needs fixingThe building and communal areas did not allow good social distancing. This was a concern during the COVID-19 inspection.
“Communal areas did not promote social distancing due to its size.” from the report
Decisions not recorded
needs fixingThe manager had not recorded the risks of choosing not to follow some best-practice guidance. Inspectors recommended that these risks should be assessed, documented and reviewed.
“When good practice guidance and recommendations had not been followed, there was no documentary evidence to show these decisions had been risk assessed.” from the report
Worn lounge chairs
minorTwo lounge chairs had worn and stained wooden and fabric arms. The manager knew about their condition, but said people had asked for them to remain.
“The wooden and fabric arms on two chairs in the lounge were worn and stained.” from the report
- 01What is your current policy on staff wearing face masks when they are within two metres of residents?
- 02How do you manage social distancing in the communal areas of the home?
- 03Have you recorded and reviewed the risks of not following any COVID-19 best-practice guidance?
- 04What action has been taken about the worn and stained arms of the two lounge chairs?
- 05What were the Caring and Responsive ratings at the previous comprehensive inspection?
This was a focused inspection of Safe, Effective and Well-led, including infection control; Caring and Responsive were not assessed and previous ratings for questions not looked at were carried forward. This explanation was written from the published report of 24 October 2020 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 Rushley House Retirement Home
5 rated inspections over 6 years: the service has held its Good rating throughout.
- March 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
Read what inspectors found at Rushley House Retirement Home →
- October 2020Requires improvementstayed Requires improvementWell-led: Good
Read what inspectors found at Rushley House Retirement Home →
- April 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 January 2011.
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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