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Rosebery Manor Requires improvement

We are carrying out a review of quality at Rosebery Manor. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 16 February 2019

Rosebery Manor 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. Rosebery Manor provides facilities and services for up to 95 older people who require personal or nursing care. The service is purpose-built and provides accommodation and facilities over three floors. The second floor provides care and support to people who are living with dementia, this area is called The Oaks. The other areas of the home provide care for people requiring 'assisted living'. Some people lead a mainly independent life and use the home's facilities to support their lifestyle. On the day of the inspection there were 74 people living at Rosebery Manor.

The registered manager had recently left the service although continued to be employed by the provider. A new manager was in post and had begun the registration process. A registered manager is a person who has registered with the Care Quality Commission 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 our inspection on 10 August 2017 we identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following concerns relating to the care people were receiving we completed a further inspection Rosebery Manor on 24 May 2018 where seven breaches of legal requirements were identified. These were in relation to a lack of consistent leadership and management oversight, risks to people's safety not always being identified and acted upon, people’s medicines not being managed safely and accidents and incidents not being adequately monitored. In addition, we found that sufficient, skilled staff were not always deployed, complaints were not always recorded and responded to, people’s dignity was not always being upheld and people’s care was not always person-centred.

Following this inspection, we issued warning notices in relation to safe care and treatment and good governance. As a result of our concerns Rosebery Manor was placed into special measures. We asked the provider to complete an action plan to show what they would do and by when to improve the key questions of Safe, Effective, Caring, Responsive and Well-led to at least good.

At this inspection we found significant improvements had been made in all areas of the service and no breaches of legal requirements were identified. The overall rating for the service is requires improvement. We could not improve the rating for well-led and safe from inadequate to good because to do so requires consistent good practice over time. We will check whether these improvements have been sustained during our next planned comprehensive inspection.

People told us they felt safe living at the home and staff understood their responsibility to identify and report any concerns of potential abuse. Staff received safeguarding training which was regularly updated. Risks to people's safety were identified and assessed.

There were enough staff to meet people's needs and regular agency staff were used where required. New staff were appointed through safe recruitment and selection processes. Accidents and incidents were reported and action taken to minimise risks and identify trends. People received their medicines in line with their prescriptions and safe systems of medicines management had been developed. Staff understood their responsibility to protect people from the risk of infection and followed appropriate infection control procedures. People lived in a safe environment which was suited to their needs and contingency plans were in place to ensure people received their support in the event of an emergency.

People’s needs were ass

Inspection areas


Requires improvement

Updated 16 February 2019

The service was safe.

Staff understood their responsibility to identify and report any safeguarding concerns.

There were detailed risk assessments in place to help keep people safe. Accidents and incidents were reviewed to minimise the risks of them happening again.

Medicines were managed safely and administration systems were regularly audited.

There were sufficient staff available and safe recruitment processes were in place.

People lived in a safe and clean environment. Staff had received training in infection control.

Although there were no breaches of regulations we need to see that the improvements made are sustained and imbedded into practice over time.



Updated 16 February 2019

The service was effective.

People were supported by staff who received training and support.

People were supported to eat and drink enough. There was a wide variety of food options for people to choose from.

People had access to healthcare and their health needs were monitored and responded to.

The service was designed to meet people's needs.

People�s legal rights were respected.



Updated 16 February 2019

The service was caring.

People were treated with kindness and respect.

Staff had developed positive relationships with people and new their needs well.

People's privacy and dignity was respected.

People's independence was promoted.



Updated 16 February 2019

The service was responsive.

A range of activities were available which were in line with people�s preferences and interests.

Care records included detailed information and guidance for staff about how people�s needs should be met.

People�s end of life care wishes were known to staff.

The provider had a complaints policy in place and people felt that any concerns raised would be acted upon.


Requires improvement

Updated 16 February 2019

The service was well-led.

Staff were supported in their roles and felt the management of the service was promoting a positive culture.

A positive culture was developing where staff understood the values of the service.

Quality assurance audits were in place and concerns identified were addressed.

People and their relatives were involved in the development of the service.

Although there were no breaches of regulations we need to see that the improvements made are sustained and imbedded into practice over time.