12 November 2020
During an inspection looking at part of the service
Roseacre is a residential care home providing personal care for up to 40 older people, some of whom were living with dementia. The home is a large purpose-built care home run by Banstead, Carshalton and District Housing Society which is a Not for Profit Charitable Society. At the time of the inspection there were 24 people living at the service.
People’s experience of using this service and what we found
People were not protected against risks associated with their care. The environment and equipment were not always clean or properly maintained. These concerns were raised at the last inspection and continued at this inspection. Staff were not confident in raising concerns around neglect and abuse and had not received appropriate training in safeguarding to ensure their knowledge in this area.
Although there were elements of good infection control practice, the systems in place to protect people from the COVID virus were not robust. People’s medicines were not always being managed in a safe way. Accidents and incidents were not always recorded, and not enough action was taken to reduce further risks to people.
There were insufficient staff deployed to ensure that people received their care when needed. The registered manager and provider did not have appropriate systems in place to review people’s dependency levels to ensure sufficient staff were on duty.
We observed instances of staff being kind and caring. However, people were not always treated with respect and dignity. The leadership at the service was not robust and there was a lack of auditing to review the quality of care. Staff did not always feel supported or valued. Notifications were not always being sent to the CQC where it was appropriate to do so. Relatives said communication was poor and people did not have opportunities to give their views about the service.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update:
The last rating for this service was Requires Improvement (published 13 January 2020). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection not enough improvement had not been made and the provider was still in breach of regulations.
Why we inspected
We carried out an unannounced comprehensive inspection of this service on 5 December 2019. Breaches of legal requirements were found.
We undertook this focused inspection to check they had followed their action plan and to confirm they were now meeting legal requirements. This report only covers our findings in relation to the Key Questions Safe, Caring and Well Led which contain those requirements.
The inspection was also prompted in part by notification of an incident whereby a service user sustained a serious injury. The information CQC received about the incident indicated concerns about the management of falls. This inspection examined those risks.
The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. 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.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Cedar Court on our website at www.cqc.org.uk.