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Archived: Rosewood Court Inadequate

Inspection Summary


Overall summary & rating

Inadequate

Updated 3 November 2017

Rosewood Court was added to the provider’s registration in April 2016. It is a purpose built care home that provides accommodation, nursing and personal care for up to 66 older people, some of whom are living with dementia.

Our last inspection took place on 11 July 2017 and included information received from the local authority on 1 August 2017. We rated the service as requires improvement with three breaches of regulations.

This unannounced inspection took place on 12 and 13 September 2017. We also received information by email from the provider on 20 September 2017. There were 19 people receiving care, and one person in hospital, at that time.

Prior to this inspection we received further concerns from the local authority and Clinical Commissioning Group in relation to the management of the service and the care people received.

Before this inspection the provider's representative told us they planned to temporarily stop providing nursing care in order for them to focus on making the necessary improvements to the service.

During our inspection visit on 12 September 2017 the provider's representative told us they had decided to close the service. They engaged a consultancy company to assist senior managers with the closure.

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. The service had not had a registered manager since January 2017. Since that time the provider had appointed five managers. The current manager took up post on 6 September 2017. However, they were not present during our inspection and senior managers told us the new manager was unlikely to return to work. The compliance manager was managing the service during our inspection. The lack of stable management had negatively impacted on the service, causing confusion and low staff morale.

The provider had failed to follow the required process to notify CQC of changes in the service’s managers.

Systems to continually assess, monitor and improve the quality and safety of care provided at the service were lacking and remained ineffective.

There were opportunities for people and their relatives to provide feedback to the provider. However, these were not always communicated to them and that little had changed as a result of their comments. Relatives were not always informed of changes in their family member’s well-being. We therefore concluded that complaints were not always thoroughly investigated and complainants were not always kept informed of the progress of their complaints.

Not all staff received sufficient training and support to carry out their roles.

Staff had not always supported people with decision making. The provider told us this would be addressed by 20 September 2017.

People’s nutritional needs were met. However, people’s health care needs were not always effectively monitored or met and people did not always receive their prescribed medicines.

Potential risks to people had not always been assessed and were not always well managed.

There was not always enough sufficiently skilled and experienced staff on duty to make sure people’s needs were fully met and people were kept safe. Staff knew how to recognise incidents of potential harm but did not always know how to, or feel confident in, reporting these.

Some people were happy with the care they received. However, staff did not always follow people’s care plans and people did not always receive the care they needed. However, we were aware the provider was in the process of reviewing people’s care plans.

People received care from staff who were kind, respectful and supported their independence. Staff treated people with dignity and respect. However, care was not always person-centred and people were not alw

Inspection areas

Safe

Inadequate

Updated 3 November 2017

The service was not safe.

Potential risks to people had not always been assessed and were not always well managed.

There was not always enough sufficiently skilled and experienced staff on duty to make sure people’s needs were fully met and people were kept safe.

Staff knew how to recognise incidents of potential harm but did not always know how to, or feel confident in, reporting these.

Medicines were not always well managed.

Effective

Requires improvement

Updated 3 November 2017

The service was not always effective.

Not all staff received sufficient training and support to carry out their roles.

Staff had not always supported people with decision making.

People’s nutritional needs were met.

People’s health care needs were not always effectively monitored or met.

Caring

Requires improvement

Updated 3 November 2017

The service was not always caring.

People received care from staff who were kind, respectful and supported their independence. However, care was not always person-centred.

People were not always involved in every day decisions about their care.

Staff treated people with dignity and respect.

Responsive

Requires improvement

Updated 3 November 2017

The service was not always responsive.

Staff did not always follow people’s care plans, not all people’s needs had been addressed within their care plans, and people did not always receive the care they needed.

There were opportunities for people to develop and maintain interests and hobbies.

Complaints were not always listened to or addressed.

Well-led

Inadequate

Updated 3 November 2017

The service was not well-led.

Effective systems were not in place to continually assess, monitor and improve the quality and safety of care provided at the service.

The changes in manager and lack of registered manager limited the provider's ability to drive or sustain the improvements that were required.

The provider had not formally notified the CQC of changes in the person managing the service.