Rosevilla Residential Home

Updated 10 February 2024

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

This inspection was completed was completed by 2 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Rosevilla Residential Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Rosevilla Residential Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there were 2 registered managers in post.

One of the registered managers was also the provider and nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 4 people who used the service and 4 family members to gather their feedback about the service provided. We spoke with 5 staff, the registered manager and nominated individual.

We looked at 11 people's care records and 6 people's records in relation to medicines. We looked at 4 staff files and a range of other records relating to the overall management of the service.

Updated 10 February 2024

About the service

Rosevilla Residential Home provides accommodation and personal care to older people, including people living with dementia. At the time of our inspection, there were 40 people living in the home.

People's experience of using the service and what we found

Governance systems failed to identify issues and drive necessary improvements to the quality and safety of the service. Issues we identified during the inspection had occurred partly due to a lack of understanding around the requirement for some actions and records that needed to be implemented in order to keep people safe.

People's prescribed medicines were not always managed safely. Risks associated with fluid thickening powder had not been considered and acted upon to ensure people were kept safe. Records required to show where and how topical medications such as creams and pain patches should be applied were not in place to evidence staff were following prescriber guidance. Advice had not been sought from a pharmacist to ensure that covert medicines (hidden in food or drink) were being given in a safe way. Staff had failed to follow prescriber guidance when administering medicines required to be taken separately to other prescribed medicines.

Risks to people's health safety and wellbeing had not always been assessed or documented in people's care plans to help staff support people safely. Risks associated with taking blood thinner medication and falls had not been considered as part of the care planning process. Staff did not have access to guidance around how to identify and respond to people who may experience low or high blood glucose levels.

Accidents and incidents were not subject to review or analysis to help identify patterns and trends. This meant there were missed opportunities to implement necessary changes to help prevent incidents occurring in the future. There were not always enough staff deployed across the service to support people safely.

Safeguarding concerns were recorded and acted upon appropriately. However, we could not always be certain they were reported to relevant agencies, including CQC, in a timely manner. We have made a recommendation regarding this.

Assessments were completed to determine people’s capacity to make specific decisions. However, there was no evidence to show that best interests processes were being followed in line with the principles of the MCA. We have made a recommendation regarding this.

Whilst people were supported to have maximum choice and control of their lives and supported by staff in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice. We have made a recommendation regarding capacity assessments and best interests processes.

The layout of the building was suitable to meet the needs of people who needed mobility equipment. However, we identified some issues regarding the atmosphere and the impact this could have on people living with dementia and those with increased anxiety and distress. We have made a recommendation regarding this.

Whilst people's needs had been assessed, we could not be certain care was being delivered in line with best practice. This was due to a lack of detailed and person-centred information in people's care plans and some monitoring charts not providing evidence that people had received their meals in line with their assessed needs.

People and family members spoke positively about the care provided by staff and told us staff were kind and caring and knew people well. Observations completed during the inspection further evidenced this.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 8 January 2022).

Why we inspected

We received concerns in relation to risk management. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. During the inspection activity, we identified further concerns relating to MCA. As a result we included the key question of effective.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to inadequate based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this report

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Rosevilla Residential Home on our website at www.cqc.org.uk

Enforcement and recommendations

We have identified breaches in relation to medicines management, risk management, staffing and governance at this inspection.

We have made recommendations in relation to safeguarding incidents, MCA and the environment.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Special measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.