CQC report explained · a residential care home
What the CQC found at Rutland House Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, July 2023
Requires Improvement; inspectors found kind care and enough staff, but serious gaps in risk management, legal safeguards and oversight.
This was an unannounced inspection on 28 June 2023. One inspector and an Expert by Experience spoke with people, relatives, a visitor, staff and managers. They observed care and checked care records, medicines records, staff files and other management records.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. The other three questions were not inspected at this visit, so their ratings were not given in this report.
Inspectors found that four people did not have the required legal applications for restrictions on their liberty. One person had no formal risk assessment or risk management plan. The home also had gaps in medicines guidance, staff recruitment records and other records.
The provider said it acted immediately after the inspection. It submitted the legal applications, added the missing risk plans, updated records and strengthened audits. CQC said it would request an action plan, monitor progress with the local authority and return to inspect.
Kind and respectful staff
People and relatives were satisfied with the care. Feedback described staff as kind, caring and respectful.
“One person told us the service was "very nice" and the staff were "very, very, kind" and "do anything you ask.” from the report
Enough staff
Inspectors found staff available to provide support when people needed it.
“There were enough staff to support people. Staff were present and available to provide support and assistance to people when this was needed.” from the report
Medicines generally given safely
People received their medicines as prescribed. Stock, balances and records were checked and medicines were stored safely.
“Our checks of medicines stocks, balances and records showed people consistently received the medicines prescribed to them.” from the report
Good response after inspection
The provider accepted responsibility and said it acted immediately to address the main problems, including adding risk plans and submitting legal applications.
“The provider responded immediately after the inspection. They told us DoLS applications had been submitted to the appropriate authority for 4 people” from the report
Clean environment and visiting
Inspectors were assured that infection prevention measures were effective. Relatives and friends could visit without unnecessary restrictions.
“There were no unnecessary restrictions on friends and relatives visiting people at the service.” from the report
Missing risk assessment
seriousOne person had recently moved in without a formal assessment or guidance for risks that could cause injury to them or others. This was a breach.
“The provider had not made sure that risks to the person's safety had been assessed and mitigated.” from the report
Unlawful restrictions
seriousFour people did not have the necessary applications for legal authorisation of restrictions on their liberty. This was a breach of safeguarding requirements.
“The provider was depriving people of their liberty for the purpose of receiving care and treatment without lawful authority.” from the report
Weak management checks
seriousAudits had not found the missing risk assessments and legal applications. Some records were incomplete or out of date, including medicines, recruitment and equipment records. This was a breach.
“Despite the assurances provided, the issues we found meant the provider's oversight of the service and governance processes had not always been effective.” from the report
Out-of-date as-required medicines guidance
needs fixingGuidance for two people's as-required medicines had not been reviewed within the home's own timescales. The provider said it was updated after the inspection.
“This increased the risk for these people of not receiving these medicines in a timely and appropriate way.” from the report
Incomplete recruitment records
needs fixingThree newer staff members did not yet have two or more references, and the files contained only basic information about how risks had been managed.
“We noted the provider had not yet been able to obtain 2 or more references for 3 staff members that had recently started work at the service.” from the report
- 01Have the required legal applications now been submitted and accepted for all four people, and how will you check that authorisations remain current?
- 02What risk assessment and management plan is now in place for the person who recently moved in, and when will it be reviewed?
- 03How are your new audits checking for missing risk plans, legal authorisations and incomplete records?
- 04How have you updated the guidance for as-required medicines, and how do you make sure it is reviewed on time?
- 05Have all staff recruitment files been completed with the required references and documented risk decisions?
This was an unannounced inspection focused on Safe and Well-led, with infection prevention and control also reviewed; the other key question ratings were not given in this report. This explanation was written from the published report of 28 July 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, March 2022
Rutland House Care Home was inspected but not rated; inspectors found good infection control during a COVID-19 outbreak.
This was a targeted inspection on 10 February 2022. Inspectors looked at infection prevention and control during a recent COVID-19 outbreak, and asked about staffing pressures. The visit was announced 24 hours in advance.
Inspectors found that the home followed infection control guidance. Visitors were screened, people and staff were tested, and staff were trained in infection control and the use of protective equipment. The home was clean, hygienic and well ventilated.
The home kept relatives updated about the outbreak and supported safe visits, video calls and telephone calls. Staffing levels were maintained, and staff worked only at this location to help reduce infection risks.
The inspection was not rated. This means it does not provide an overall quality rating or ratings for the full range of care.
Infection control
The home followed relevant guidance during a COVID-19 outbreak. Inspectors were assured that infection risks were being managed.
“During a recent outbreak of COVID-19 the provider had followed guidance and advice from the relevant agencies to ensure the safety of people and staff.” from the report
Communication with relatives
Relatives were given regular updates and help with safe visits. Alternative contact was supported when relatives could not visit.
“The provider had been open and transparent with relatives about the outbreak, providing regular updates.” from the report
Clean environment
The home was clean, hygienic and well ventilated. Enhanced cleaning took place daily.
“The environment was clean, hygienic and well ventilated. Enhanced cleaning took place throughout the environment on a daily basis.” from the report
Staff training and protection
Staff had infection control training and used protective equipment correctly. Testing and vaccination arrangements were also in place as required at the time.
“Staff had been trained in COVID-19, infection prevention and control (IPC) and in the use of personal protective equipment (PPE).” from the report
Inspectors raised no specific concerns in this report.
- 01How would you manage staffing pressures if there was another COVID-19 outbreak?
- 02What visiting arrangements are currently in place during an infection outbreak?
- 03How would you keep relatives updated if people could not receive normal visits?
- 04How often are infection control checks and audits carried out?
- 05What were the home’s ratings for caring, effective, responsive and well-led care at the previous full inspection?
This was a targeted inspection of infection prevention and control and staffing pressures; the service was inspected but not rated and the other care areas were not covered. This explanation was written from the published report of 2 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.
Every inspection of Rutland House Care Home
6 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- July 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2022Inspected but not ratedSafe: Inspected but not rated
- February 2018Goodstayed GoodSafe: GoodWell-led: Good
- April 2017Goodup from Requires improvementSafe: GoodWell-led: Good
- November 2016Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2015Goodstayed GoodWell-led: Good
- February 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 12 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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