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Rock Cottage Care Services Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 2 October 2020

About the service

About the service: Rock Cottage is a 36-bedded residential care home that was providing personal and

nursing care to 30 people aged 65 and over at the time of the inspection.

People’s experience of using this service and what we found

The service had improved since our last inspection, but further improvements were still needed.

People received their medicines safely. However, we found that audit systems in place could not sufficiently identify the numbers of medicines people had in stock.

People's support needs were planned and assessed for however, care files were inconsistent with information relating to person centred care and management of risks to people required strengthening.

Governance systems were not being applied consistently meaning that the services people received were

not always effectively monitored.

There were inconsistent recording systems to evidence if people had been repositioned in accordance with their care plan needs.

The service was clean and free of malodour. There were a number of personal protective equipment (PPE) stations positioned throughout the home and staff wore appropriate PPE. Where new admissions came into the home, they were isolated for 14 days with evidence on their room door of when the isolation started.

People told us they felt safe in the home.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The rating at the last inspection was requires improvement (report was published on 09 April 2019) You

can read the report from our last comprehensive inspection by selecting the 'all reports' link for Rock Cottage care services on our website at

Why we inspected

We received concerns in relation to people's nursing care and how the service was promoting people's

safety. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We undertook this focussed inspection to check they had followed their action plan and to confirm they now

met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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 the service has

remained the same.

We have found evidence that the provider needs to make improvements. Please see the safe and well led

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


We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took

account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering

what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

We will continue to discharge our regulatory enforcement functions required to keep people safe and to

hold providers to account where it is necessary for us to do so.

We have identified a breach of Regulation 17 (Good Governance) of the Health and Social Care act 2008 (Regulated activities) Regulations 2014. The registered person had not established an effective system to enable them to assess, monitor and improve the quality and safety of the service provided.

Follow Up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas


Requires improvement

Updated 2 October 2020

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 2 October 2020


Requires improvement

Updated 2 October 2020


Requires improvement

Updated 2 October 2020


Requires improvement

Updated 2 October 2020

The service was not always well-led.

Details are in our well-led findings below.