CQC report explained · a residential care home
What the CQC found at The Rookery 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, February 2022
Targeted inspection, not rated; inspectors were assured about infection control, although some equipment and furniture were visibly worn.
This was an announced, targeted inspection on 25 January 2022. It focused on infection prevention and control during a COVID-19 outbreak, and on whether staffing pressures affected care.
Inspectors found the home clean, with cleaning schedules, extra cleaning of high-touch areas and enough protective equipment. Visitors were screened and required to show a negative lateral flow test. Inspectors were also assured that the home was managing testing, isolation, admissions and visiting safely.
Some furniture and equipment looked worn. The deputy manager said this would be raised with the proprietor. The inspection did not give a quality rating. Safe was recorded as inspected but not rated.
Infection control
Inspectors were assured that visitors were screened and that the home was managing infection risks, including outbreaks and admissions.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Protective equipment
There were ample supplies of PPE, with stations placed in key areas so staff could access it quickly.
“PPE stations were located in the key areas of the home allowing staff to have quick and easy access to hand sanitisers or face masks.” from the report
Cleaning arrangements
The home had cleaning schedules and increased cleaning during the outbreak, including disinfection of frequently touched surfaces.
“Enhanced cleaning had been introduced which included regular disinfection of high touch points, such as handrails or door handles.” from the report
Contact with relatives
A system was in place to support people to keep in contact with relatives and other important people.
“People using the service were supported to maintain contacts with their relatives.” from the report
Worn equipment and furniture
minorSome equipment and furniture were visibly worn. The deputy manager said this would be raised with the proprietor, but the report does not say that repairs or replacements had already happened.
“The home looked clean and there were cleaning schedules in place; however, some items of the equipment and furniture were visibly worn.” from the report
- 01Which equipment and furniture were found to be worn, and what has been repaired or replaced since the inspection?
- 02How would you manage staffing pressures if COVID-19 or another outbreak affected staff availability?
- 03How are visitors screened and supported to visit people safely now?
- 04How do you manage isolation and communal areas for people who cannot self-isolate because of advanced dementia?
- 05How do relatives keep in contact with people if visiting is restricted?
This was a targeted inspection of infection prevention and control and COVID-19-related staffing pressures; the service was inspected but not rated and the other questions were not assessed in this report. This explanation was written from the published report of 11 February 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, June 2021
Requires Improvement; inspectors found safe care and clear progress, but the home's management systems were not yet fully reliable.
This was an unannounced focused inspection on 12 May 2021. One inspector observed care, spoke with three staff members and checked care, medicine, recruitment, training and management records. The inspector also checked infection control arrangements.
The home was rated Good for Safe. Risks were being assessed and managed, medicines were given as prescribed, infection control had improved and there were enough staff to meet people's needs. Problems found at the previous inspection had been addressed, including issues with risks, medicines, staffing and recruitment.
The home was rated Requires Improvement for Well-led. The provider had introduced better audits, action plans and monitoring, but inspectors were not yet assured that improvements would last. Some risk information was incomplete and staff recruitment records still lacked interview notes.
The overall rating remained Requires Improvement. The other three areas, Effective, Caring and Responsive, were not examined during this focused inspection, so their previous ratings were used in the overall rating.
Safer risk management
Individual and environmental risks were now being assessed, reviewed and managed. The home was tidier and the risk from loose dog toys had been reduced.
“Risks for people were now being assessed, managed and monitored effectively.” from the report
Medicines
Medicines were given as prescribed. New checks, staff competency assessments and medicine audits had improved how medicines were managed.
“At this inspection new systems were in place and showed us a more robust working and monitoring process for PRN medicines.” from the report
Infection control
The home followed the infection control measures reviewed by inspectors, including use of protective equipment, testing, cleaning and updated COVID-19 guidance.
“We were assured that the provider's infection prevention and control policy was up to date.” from the report
Staffing
Inspectors found enough staff to meet people's needs. Training and recruitment checks had improved, although some records still needed finishing.
“There were sufficient staff to meet people's needs.” from the report
Improvement planning
The provider had put action plans and stronger quality checks in place. These were intended to identify and address problems more quickly.
“Robust action plans were in place to monitor and address any concerns as they arise.” from the report
Risk records incomplete
needs fixingSome information about the level of risk for people and staff at high risk of COVID-19 was not complete. The manager said this would be reviewed and updated immediately.
“However, more work was required as the level of risk was not complete.” from the report
Recruitment records
needs fixingStaff files had improved but interview notes were still not fully completed. Inspectors were not yet assured that the improvement was being maintained.
“Staff files showed there had been some improvement, but still lacked completion for the interview notes.” from the report
Improvements not yet embedded
needs fixingThe provider had made progress, but inspectors wanted to see that the new systems continued to work over time. This was why Well-led remained Requires Improvement.
“Whilst improvements had been made these need to be sustained and embedded.” from the report
- 01What has been done to complete and regularly review the risk information that inspectors found was incomplete?
- 02How do you now check that staff recruitment files contain complete interview notes and all required information?
- 03How will you show that the new audits and action plans continue to identify and fix problems?
- 04What training have night staff completed on medicines, and how are their competencies checked?
- 05What were the previous ratings for Effective, Caring and Responsive, which were not assessed during this inspection?
This was a focused inspection of Safe and Well-led; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 23 June 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 The Rookery Care Home
6 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- February 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- June 2021Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2021Requires improvementdown from GoodSafe: InadequateWell-led: Requires improvement
- February 2019Goodstayed GoodSafe: GoodWell-led: Good
- August 2016Goodup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016Inadequatedown from Requires improvementSafe: Inadequate
- December 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2015
Registered with the Care Quality Commission on 16 February 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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