CQC report explained · a nursing home
What the CQC found at The Rosary Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, March 2022
The Rosary Nursing Home was rated Good; inspectors found caring and safe support, but some care records and pressure-ulcer reviews needed improvement.
This was an unannounced focused inspection on 17 February 2022. Inspectors visited the home, spoke with people, relatives, staff and a health professional, observed care, and checked care plans, medicines records, training records and management systems.
The home was rated Good for Safe, Effective and Well-led. People generally received safe, kind and personalised support. Medicines were managed safely, people could access health professionals, and staff and relatives were mostly positive about the home.
Inspectors found that some care plans and risk assessments did not fully record what staff knew about people or the decisions made for them. Reviews of pressure ulcers had not always been used to learn lessons. The provider had identified many of these issues and had action plans or had made changes after the inspection.
Staff knew people well
Staff understood people's needs and how to keep them safe. Inspectors saw people appearing comfortable with staff and receiving support at a pace that suited them.
“People were supported by staff who understood how to keep them safe and recognise signs of abuse.” from the report
Safe medicines support
Medicines were given safely and staff were checked as competent. People received support in a caring way and medicines requiring extra storage and checks met current guidance.
“People were supported to receive their medicines safely following their preferred preference.” from the report
Good access to health care
People could see health professionals, including a weekly GP visit. Specialist advice was included in care plans where it had been obtained.
“People had access to healthcare services. The GP visited weekly and nurses said they had access to the GP between visits if required.” from the report
Positive culture
People, relatives and staff were generally positive about the management and atmosphere. The home held meetings so people and staff could share views and ideas.
“The registered manager and provider promoted a positive culture that valued people and the staff.” from the report
Care records were not always complete
needs fixingSome care plans and risk assessments did not fully reflect people's needs, changes, or decisions made for them. Inspectors found no impact on people during the inspection, and the provider had plans to improve record keeping.
“Care records, including risk assessments, did not always reflect this knowledge.” from the report
Pressure-ulcer learning was incomplete
needs fixingThe home did not always analyse the development of pressure ulcers to identify lessons. New systems were shared after the inspection to address this.
“However, systems were not always in place to learn lessons from when people developed pressure ulcers.” from the report
Some training gaps remained
minorThere were gaps in staff training, although completion dates had been planned and some staff had role-specific training.
“There were gaps in training which already had planned completion dates” from the report
Some areas needed more support or repair
minorInspectors said more support could be provided to people choosing to eat outside the main dining room. Some parts of the home looked tired and needed redecoration, with work planned.
“Improvements could be made to increase support for people choosing to eat in their bedrooms or other areas of the unit.” from the report
- 01How quickly will you update my relative's care plan and risk assessments after admission or any change in their needs?
- 02What new system do you use to review pressure ulcers and share lessons with staff?
- 03How do you make sure mental-capacity assessments and best-interest decisions are recorded in the care plan?
- 04How do you support people who choose to eat in their bedroom or elsewhere in the dementia unit?
- 05Which staff training was outstanding at the inspection, and has it now been completed?
This was an unannounced focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected in detail and their previous ratings were carried forward. This explanation was written from the published report of 17 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, March 2018
The Rosary Nursing Home was rated Good; inspectors found safe, kind and personalised care, with care records still needing further improvement.
This was an unannounced inspection on 20 and 21 February 2018. Inspectors spoke with people living at the home, visitors, staff and healthcare professionals. They observed care and checked care plans, medicine records, staffing records, complaints and quality checks.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines practice, suitable training, kind care, activities and approachable management.
The home had improved since the previous inspection in January 2017. Staffing had been better organised, people received more social stimulation, care was more person centred and quality checks were more effective.
Some care plans were bulky, so it was not always easy to find the latest information about how people wanted to be supported. The home was moving to an electronic system to improve this.
Staffing and safety
Inspectors found staff were available when people needed help and were deployed effectively. Recruitment had reduced reliance on agency staff, especially during the day.
“People were supported by adequate numbers of staff who were effectively deployed to keep them safe and support them with activities of daily life.” from the report
Kind and respectful care
Staff knew people well and adapted their approach to individual preferences. Inspectors saw warmth, compassion, privacy and dignity in day-to-day care.
“People were cared for by staff who were extremely kind and caring.” from the report
Activities and social contact
People were offered activities or social contact every day. Activities were adapted to people's wishes and abilities, including baking, singing and time for conversation.
“Records were kept which showed that everyone was offered some form of activity every day.” from the report
Improved management
The home had stronger quality checks and acted on feedback, incidents and complaints. Inspectors found a clearer commitment to ongoing improvement.
“People could now be confident that the provider's quality assurance systems were effective in identifying shortfalls and taking action.” from the report
Care records were difficult to use
minorSome care plans were bulky, making it difficult to find up-to-date information about people's preferences and support. The home said it was changing to an electronic system.
“However some care plans we read were bulky and it was difficult to easily find up to date information about how people liked to be supported.” from the report
- 01How far has the planned move from bulky paper care plans to the electronic system progressed?
- 02How do you make sure staff can quickly find the latest information about my relative's preferences and support needs?
- 03How many agency staff are currently used at night, and how do you make sure night staff know residents well?
- 04What activities would be suitable for my relative, and how would you adapt them if they have dementia or communication difficulties?
- 05How are end-of-life wishes recorded, and how would you involve my relative, their representatives and healthcare professionals in decisions about treatment?
This was an unannounced inspection of the overall quality of the home and covered all five key questions; the previous inspection was in January 2017. This explanation was written from the published report of 17 March 2018 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 Rosary Nursing Home
5 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- March 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- February 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Good
- September 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 16 December 2010.
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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