Rosegarth Residential

living with dementia. At the time of this inspection, 16 people were using the service.

We found the following examples of good practice.

People were supported to have visitors and safe visiting processes were followed in line with national guidance, including visits in the local community. Alternative arrangements were available to support people to maintain contact with their family and friends in the event of an outbreak.

Risks to people and staff in relation to COVID-19 had been assessed and action taken to manage the risks.

Staff took part in regular testing for COVID-19. They appropriately wore personal protective equipment (PPE) to minimise the risk of infections spreading.

People’s experience of using this service: The quality of care provided to people had improved since the last inspection. People told us they were happy, and relatives had noticed the improvements.

The provider had worked hard since the last inspection to make changes that impacted positively on people's experience of using the service. The registered manager led by example to ensure people received a good service. People and staff told us the registered manager was approachable. Management oversight had been improved.

People received their medicines safely and on time and their health was well managed. We have made a recommendation on medication protocols. Care and support were tailored to each person's needs and preferences. People were cared for in a clean environment free from the risk of infection.

Recruitment checks were carried out to ensure staff were suitable to work in the service. Staff had attended training specific to people's needs. Further training was being planned to ensure all staff were skilled to meet the needs of people. We have made a recommendation on staff training.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The systems and records in the service now supported this practice.

People were involved in more activities and their diverse needs had been considered. People felt staff were kind and caring.

At the last inspection there were five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection these breaches had been met.

Rating at last inspection: Requires Improvement (published 26 February 2019)

Why we inspected: We inspected the service shortly after our previous inspection as we needed to check on progress and confirm that no further action was necessary.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

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

Rosegarth Residential is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The service is registered to provide accommodation and care for up to 26 older people, some of whom are living with dementia. At the time of our inspection there were 17 people living at the service.

At the last comprehensive inspection, completed in May 2018, we found that there were six breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to person-centred care, the safe delivery of care and treatment, premises and equipment, staffing, recruitment and the overall oversight and governance of the service. The overall rating for the service at that time was 'inadequate' and the service was placed in Special Measures. We completed a focused inspection in August 2018 and looked at the safe and well-led domains only. At that inspection we found two continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the safe delivery of care and treatment and the overall oversight and governance of the service. We also identified a new breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Need for consent. The service continued to be rated ‘inadequate’ overall at that time, and it remained in special measures.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

At this inspection we found that there were five breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to the safe delivery of care and treatment, need for consent, competent and skilled staff, the overall oversight and governance of the service and a failure to display the rating from our previous inspection. We also identified one breach of the Care Quality Commission (Registration) Regulations 2009 related the provider’s failure to notify the Commission of all notifiable incidents.

The service is required to have a registered manager in post. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The service has had three new managers since January 2018. The most recent manager had started the process of registering with CQC.

A caring culture was demonstrated by some staff throughout the inspection. However, some staff lacked knowledge about people and respect for people was not always evidenced through service delivery.

Not all risk assessments in place were effective at mitigating risks. Environmental risk assessments were out of date and required reviewing to ensure they were fit for purpose. Improvements in fire safety were required to ensure people were safe. Additional fire training was being sought by the area manager.

Staff received an effective induction which included regular contact with the provider. Training of staff still required improvement to ensure that staff were knowledgeable in the needs of people using the service. Some staff lacked knowledge regarding people’s specific needs despite processes in place to address this.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible; the policies and systems in the service did not support supported this practice.

Recruitment of staff was found to be robust and staffing numbers were observed to be sufficient to meet people’s needs.

The provision of activities had improved. Further improvements were being considered and planned by the manager. Staff were observed to be less task focused and spent more time with people.

Care plans were person-centred and represented people’s up to date needs. Reviews were held regularly.

People were supported with food and fluid intake and recording of this had greatly improved since the last inspection.

The provision of pressure area care had improved since our last inspection. Further improvements were required to ensure effective oversight of this area of care. The manager was considering ways in which this could be implemented.

There was a complaints policy in place and records showed that matters were investigated and responded to. Lessons learnt were not evidenced in relation to complaints or accidents and incidents. This required improvement to ensure the risks to people were considered and reduced.

Staff were positive about the new manager in place. They felt able to approach all levels of management including the provider, if they had any concerns.

A number of systems and processes had been introduced to monitor the quality of care provided to people. These systems required further review or embedding to ensure that they were effective at ensuring improvements in service delivery continued to be made.

The management showed a willingness and enthusiasm to deliver the changes necessary to meet the regulations. However, improvements were still required to ensure that the management in place could identify the shortfalls that CQC have continued to identify as part of the inspection process.

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

Rosegarth Residential is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The service is registered to provide accommodation and care for up to 26 older people, some of whom are living with dementia. At the time of our inspection there were 18 people living at the service.

At the last inspection, completed in May 2018, we found that there were six breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to person centred care, the safe delivery of care and treatment, premises and equipment, staffing, recruitment and the overall oversight and governance of the service. The overall rating for this service was 'Inadequate' and the service was in 'Special measures'.

This report only covers our findings in relation to the safe and well-led domains. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Rosegarth Residential on our website at www.cqc.org.uk.

At this inspection we found that there were three breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to the safe delivery of care and treatment, need for consent and the overall oversight and governance of the service.

The service is required to have a registered manager in post. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The service had a new manager in post since January 2018, however the previous manager is yet to deregister and the new manager had not started the process of registering with CQC.

Despite the service being rated as inadequate at the last comprehensive inspection the provider had failed to deliver the required improvements to ensure people receive safe care and treatment in line with the fundamental standards.

The service failed to accurately assess the risk to people and ensure that measures were in place to reduce and mitigate this risk. People were exposed to increased risks within the service due to inadequate care provided. People failed to receive adequate support in relation to their tissue viability needs.

People in receipt of covert medicines did not have the required plans in place. Decisions regarding the administration of covert medicines and the use of monitoring restrictions had not been agreed in line with the Mental Capacity Act and through best interest’s meetings.

The systems which the provider had in place to assess the experience of people receiving care had not identified the concerns we observed during our inspection. There had been a failure to rectify the failings identified during our last inspection and this meant people continued to receive inadequate care.

The overall rating for this service remains 'Inadequate' and the service is therefore still in 'Special measures'. Services in special measures will be kept under review and, if we have not taken immediate enforcement action, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe and there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

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

This inspection took place on the 3 and 14 May 2018. Both days were unannounced. The inspection was responsive in part due to a matter being investigated by the local authority safeguarding team.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

The service is required to have a registered manager in post. A registered manager is a person who has registered with CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At the time of the inspection there was a manager in place but they had not registered with the CQC.

Measures required to reduce the risk of harm to people were not always in place. This included exposing people to environmental risks around the building and its grounds. Infection control measures were not sufficient to prevent the risk to people of infections spreading.

Medicine procedures and systems were in place however some improvement was required to ensure that medicine practices were safe. Staff had a basic understanding of how to safeguard people from abuse.

Recruitment processes were in place but these needed to be more robust.

Staff aimed to deliver a good standard of care that was caring. Some staff demonstrated knowledge of people and this helped them to provide some person-centred care. However, staff were not sufficiently trained or supported to meet the needs of the people they were supporting.

Communication between staff and people using the service was not always appropriate or in line with best practice.

Care plans demonstrated that the principles of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) had been applied. Monitoring of DoLS applications need to be more robust. People’s wider needs were not being met by meaningful activities.

We were unable to clearly establish if people’s nutrition and hydration needs were catered for as record keeping in this area was poor. The provider needed to make changes to the meal time experience to ensure that this was pleasant and followed best practice.

The manager had used a variety of methods to assess and monitor the quality of care. However, the governance systems had not picked up all the shortfalls identified during the inspection. Where shortfalls had been identified, action to address these was not timely.

Relatives we spoke with gave positive feedback about the service and the staff. Professionals praised the current manager for their commitment to building professional working relationships between agencies.

You can see what action we told the provider to take at the back of the full version of the report.

At the last inspection in March 2015, the service was rated as Good. At this inspection we found that the service remained Good.

There continued to be sufficient numbers of staff employed to make sure people received the support they needed, and those staff had been safely recruited. People told us they felt safe living at the home.

Staff had continued to receive appropriate training to give them the knowledge and skills they required to carry out their roles. This included training on how to protect people from the risk of harm.

People were supported to have maximum choice and control over their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Staff were kind, caring and patient. They respected people’s privacy and dignity and encouraged them to be as independent as possible.

Care planning described the person and the level of support they required. Care plans were in the process of being re-designed and were an accurate record of the person and their care needs.

Activities were provided for people, including walks with staff into the town and on to the seafront.

People understood how to express any concerns or complaints and were given the opportunity to feedback their views of the service provided.

The manager had submitted their application for registration to the Care Quality Commission. Staff and relatives reported that the service was well managed.

The manager carried out audits to ensure people were receiving the care and support that they required, and to monitor that staff were following the policies, procedures and systems in place.

Further information is in the detailed findings below.

People who lived at the home told us that they were satisfied with the support they received. We saw that there were care plans in place and that these had been reviewed regularly to ensure that they contained up to date information. We observed that medication was administered in a safe way by staff who had received appropriate training.

Special diets were catered for and the people who we spoke with praised the standard of the meals provided. One person said, "The meals here are lovely". Quality assurance information evidenced that people who lived at the home were consulted about various aspects of their care to ensure that their needs were being met.

Staff had received training on topics that helped them to provide the care and support needed by people who lived at the home. However, the training matrix was not up to date so there was no full record of staff's training achievements and requirements.

Quality monitoring at the home had been increased and this included various audits that had been implemented to measure how systems were being adhered to by staff and to identify what improvements needed to be made.

At this inspection we found that improvements had been made in recruitment practices. Two written references and a Disclosure and Barring Service (DBS) check had been obtained prior to people commencing work at the home.

New employees had provided the home with training certificates to evidence training they had undertaken at previous places of employment. We also found that new staff had completed appropriate induction or refresher training when they had first started to work at the home to ensure that they had the skills needed to care for or support the people who lived there.

We found that people had care needs assessments in place that identified the support they required from staff and their ability to make decisions about their day to day lives. When people lacked the capacity to make decisions about important aspects of their life, a best interest meeting had been held to assist them with decision making.

We saw that care plans recorded information that would assist staff to support people in the way they wished to be supported and we observed on the day of the inspection that care was provided in a sensitive manner. Care plans were reviewed and updated on a regular basis and this included consultation with health care professionals.

Staff had undertaken training on safeguarding adults from abuse and displayed an understanding of different types of abuse. People told us that they felt safe living at the home.

There were sufficient staff on duty but we were concerned that some staff had not been employed using robust recruitment procedures and that this left people who lived at the home at risk of harm.

People had been made aware of the complaints procedure and told us who they would speak to if they had a complaint.

We were concerned that we had not been informed of the imminent absence of the registered manager.