Archived: Roseacre

Updated 17 December 2020

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 Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Due to concerns raised with us on the first day of inspection about the practices of staff we returned to the service for a second day.

Inspection team

Our inspection was completed by two inspectors.

Service and service type

Roseacre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and health care professionals that work with the service. We used this information to plan our inspection.

During the inspection

We spoke with six people who used the service about their experience of the care provided. We spoke with 14 members of staff including the registered manager and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also spoke with one health care professional. We reviewed a range of records including five people’s care records and medication records.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at policies and quality assurance records. We also spoke with five relatives and received feedback from two health care professionals.

Updated 17 December 2020

About 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.