Rosalyn House

Rosalyn House is a residential care home registered to provide accommodation and personal care and/or nursing care for up to 46 people. Some people may be living with dementia, a physical disability or a sensory impairment. At the time of our inspection there were 38 people living at the service.

The home is built over three floors. All bedrooms have an ensuite shower and toilet. There are shared living areas on each floor. In addition, the care home has an enclosed garden and courtyard which is available to people, their relatives and visitors.

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

Since the last inspection the provider had made improvements to the environment and decoration in the home.

Provider governance and oversight had improved at the home. New systems had been introduced to identify and address shortfalls in the service and were used to drive improvements.

Care plans and risk assessments had been reviewed and contained information to guide staff in the delivery of person-centred care.

Recruitment had taken place and the use of agency staff had been reduced. Staff treated people with dignity and respect. People were familiar with the staff and appeared to be comfortable speaking with them.

People had access to activities in the home and the local community. One relative told us, "The picture board on display in the home is lovely to see with all the activities which the people do and their smiling faces." Another relative said, "The activity team keeps everyone motivated.”

Staff received training which supported them to provide safe care. Staff understood their role and the expectations of the registered manager. The registered manager completed ongoing checks of the staff practice to ensure this remained safe.

We received several positive comments from relatives about the staff. These included, “The staff are caring and attentive.” And, “The staff are genuine and care about people and their needs.” Another relative said, “The staff and registered manager are professional, friendly and caring.”

The home was clean and had no unpleasant odour. Cleaning schedules were in place which included the cleaning of frequently touched areas.

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

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 05 November 2019) and there were breaches in regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We undertook this comprehensive inspection to check the provider had followed their action plan and to confirm they now met legal requirements.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Rosalyn House on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

• The registered manager and staff team were following effective infection control procedures to help manage the COVID-19 outbreak.

• Effective arrangements were in place for visiting professionals which included a check of vaccination status and ensuring that a negative lateral flow test (LFT) had been carried out.

• Visiting procedures were clearly displayed for visiting relatives and professionals. When the service was not in a COVID-19 outbreak relatives and friends were able to visit people in line with government guidance. Since the outbreak, relatives were able to see loved ones with window visits or using video and phone calls.

• The service looked clean and smelled fresh. Housekeeping staff followed cleaning schedules which were checked by the management team to ensure they were completed effectively.

• Staff deployment had been changed to help ensure the spread of infectious diseases were minimised. Staff were now assigned to work on one floor of the service only. The registered manager told us that staffing levels had been maintained to a good standard thanks to staff picking up overtime and regular agency staff working solely at the service.

• Staff had training in infection control and the use of personal protective equipment (PPE). We observed staff using PPE correctly.

• People who were COVID positive had been supported to isolate in their rooms in line with guidance. Effective care was in place for these people and staff wore and disposed of PPE correctly when supporting these individuals. Staff made sure that people were not socially isolated and ensured they spent time with them whilst they were isolating.

• Staff made sure that people's wellbeing was maintained during the COVID-19 outbreak. People told us about how kind and caring staff were and how they were supported to follow interests and past times such as bingo, art and crafts or watching television.

• Staff told us they were well supported by the provider and felt safe working at the service during the outbreak. Risk assessments were in place for people using the service and the staff team to help ensure they stayed safe.

Rosalyn House is a nursing and residential care home providing personal and nursing care to 40 people aged 65 and over at the time of the inspection. The service can support up to 45 people. Accommodation is set over three floors which includes an area dedicated to nursing care.

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

The provider had taken over Rosalyn House in April 2019 and had started a refurbishment programme. They had identified that the service was no longer ‘Good,’ and work was needed to correct this. However, we did find shortfalls which included how the management team were monitoring and assessing the quality of the service. Audits were not always effective at identifying issues and making plans to correct these.

We found some safety concerns when we inspected. Staff had not received training in how to always safely manage the needs of people who required additional oxygen. An oxygen cylinder was not always stored safely. Potential risks to people were not always assessed or managed to promote their safety.

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

Staff received training in key areas, but they did not receive training relevant to all those who they supported. New staff received an induction, but the competency checks were not sufficient to show or test if they were capable of working independently with people. Ongoing competency checks for staff were not completed, despite the provider's view about staff practice. Staff said they did not feel supported by the management. They understood they should be challenged if something went wrong, but they felt that their good work and commitment was not praised.

There was not enough staff to meet people’s needs at times. This included spending time with people in conversation and in a social way. They also said they did not have time to look at people’s records.

Staff were seen to be consistently kind to people. Unfortunately, we saw incidents when senior staff and management were not respectful or thoughtful towards some people they supported. People’s dignity was not always promoted by staff and the management team.

People who were at risk of being an unhealthy weight were being regularly checked and professional support had been sought to help them. The manager monitored these people to check they were well. People were also supported to get the right medical intervention when they were unwell. Staff were good at identifying this.

People did not feel involved in the meal and food choices offered to them. Some people and relatives felt the quality of the food was not always as good as it could be. People spoke positively about the chef.

The provider ensured there were staff whose focus was to provide activities. However, they were unable to support lots of people and they were often in one part of the home with limited numbers of people. Staff did not have time to really engage with people in a social way. The management team had not tried to ensure or check that people’s individual interests and what they enjoyed was being promoted and explored at the home.

Staff had a good understanding of how to protect people from possible abuse. Safe recruitment checks were in place. People told us that they felt safe. People received their medicines as prescribed.

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

Rating at last inspection

The last rating was Good (published in 17 November 2017). Since this rating was awarded the provider has changed but the legal entity remained the same.

Why we inspected

The inspection was prompted in part due to concerns received about catheter and pressure care, nursing care, staffing levels and people’s general experience of living at the home. A decision was made for us to inspect and examine those concerns.

We have found evidence that the provider needs to make improvements, but we also found evidence of good practice. Please see the Safe, Responsive and Well Led sections of this full report.

We have identified breaches in relation to the governance of the service, and how people's safety was being promoted and managed at the home. You can see what action we have asked the provider to take at the end of this full report.

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.

Following our previous comprehensive inspection in November 2016, we gave this location an overall rating of ‘Inadequate’ and was therefore placed into ‘special measures’.

At that inspection we found that people’s risk assessments and management plans were in place for each person, however they were ineffective. We found assessments had not always been updated or reviewed and lacked information to guide staff in reducing levels of risks to people. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found that medicines were not managed safely. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

There were ineffective systems in place to protect people from harm. Potential safeguarding incidents had not been reported to the local authority or the Care Quality Commission (CQC). This was a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People were not involved in decision making in relation to their care and support. This was a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Care plans did not accurately reflect people’s current needs and lacked personalisation. This was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff did not receive frequent supervision and no appraisals had been conducted in 2016. This was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Systems and processes for governance and quality assurance were ineffective and failed to assess, monitor and improve the quality of care being provided or mitigate the risk of harm to people living at the service. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can read the report from this comprehensive inspection by selecting the 'all reports' link for Rosalyn House on our website at www.cqc.org.uk.

The provider submitted an action plan to tell us how they would meet these regulations and the timescale they intended to have them met by. We carried out this unannounced comprehensive inspection on 27 September 2017, to see if the provider had made the necessary improvements to meet these breaches of regulations.

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.

There was a registered manager in post.

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.

People using the service felt safe. Staff had received training to enable them to recognise signs and symptoms of abuse and felt confident in how to report them.

People had risk assessments in place to enable them to be as independent as they could be in a safe manner. Staff knew how to manage risks to promote people’s safety, and balanced these against people’s rights to take risks and remain independent.

There were sufficient staff, with the correct skill mix, on duty to support people with their needs. Effective recruitment processes were in place and followed by the service. Staff were not offered employment until satisfactory checks had been completed.

Medicines were managed safely. The processes in place ensured that the administration and handling of medicines was suitable for the people who used the service.

Staff received an induction process and on-going training. They had attended a variety of training to ensure they were able to provide care based on current practice when supporting people. They were supported with regular supervisions and appraisals.

People were supported to make decisions about all aspects of their life; this was underpinned by the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Staff were knowledgeable of this guidance and correct processes were in place to protect people. Staff gained consent before supporting people.

People were able to make choices about the food and drink they had, and staff gave support when required to enable people to access a balanced diet. There was access to drinks and snacks throughout the day.

People were supported to access a variety of health professional when required, including opticians and doctors, to make sure they received continuing healthcare to meet their needs.

Staff provided care and support in a caring and meaningful way. They knew the people who used the service well. People and relatives, where appropriate, were involved in the planning of their care and support. Care plans reflected people’s assessed needs.

People’s privacy and dignity was maintained at all times.

People were supported to follow their interests and join in activities if they chose to.

People knew how to complain. There was a complaints procedure was in place and accessible to all. Complaint had been responded to appropriately.

Quality monitoring systems were in place. A variety of audits were carried out and used to drive improvement.

This inspection took place on 8 and 9 November 2016, and was unannounced. At the last inspection in November 2015, we asked the provider to take action to make improvements to the management of medicines and the assessment of risks for people living in the service. We received a provider action plan which stated the service would meet the regulations by 30 September 2016. This action had not been fully completed.

The service has a registered manager. However the registered manager had taken the post of the deputy manager and was no longer responsible for the day to day management of the service. A new manager had been appointed in April 2016. 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.

During this inspection we found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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.

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.

Potential safeguarding incidents had not been recognised and referrals to the local authority safeguarding team had not been made appropriately. Action was not taken to ensure that people were protected from the risks of abuse and harm. Staff understood their responsibilities with regards to safeguarding people and they had received training.

People were exposed to unnecessary risks. Risks assessments in place were ineffective, had not been reviewed and did not offer robust guidance to staff on how individual risks to people could be minimised.

Incidents and accidents which occurred in the service were not consistently reviewed by management to identify patterns and trends or to ensure action to prevent reoccurrence was identified. Lessons were not learnt from incidents which increased the risk that they would be repeated.

There were consistent numbers of staff on duty to meet people's needs however people experienced delays in responses to their call bells and receiving care and support.

Medicines were not managed safely and audits completed were ineffective in identifying issues and concerns found during our inspection. People were exposed to the risk of harm from unsafe storage of medicines, inaccurate stock levels and poor record keeping.

Staff had not received training identified as being required by the service. There was not an ongoing training programme in place for staff to give them the skills they required for their roles. Staff had not been provided with regular supervision or appraisals to assist in identifying their learning and development needs, raise concerns or seek any additional support they may require in completing their roles

People were not involved in decision making and the requirements of the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards were not met. However staff sought people’s consent before any care was provided.

There were mixed opinions with regards to the activities provided at the service. There were limited activities on the day of our inspection and staff we observed did not have opportunities to engage people in social conversation.

People's needs had been assessed. Care plans took account of individual needs but lacked detail with regards to people's preferences, choices and individuality. Care plans and risk assessments had not been regularly reviewed to ensure that they were reflective of people's current care needs and did not always give clear instructions to staff on how best to support people. The lack of personalised, current information within care plans meant that people were at risk of not having all of their health and social care needs met which could have a negative impact on their health and well-being.

Complaints were not consistently managed, recorded or responded to.

Quality assurance processes were not robust, effective or used to improve the service being provided. Where concerns were identified there was inconsistencies within the responses. Audits completed consistently failed to identify the concerns found during our inspection. As a result of the failure of these audits risks to people’s safety had not been identified and action had not been taken to reduce those risks. This further increased the risk of potential harm to people.

The provider and manager had not acted upon previous inspection feedback with a view to evaluate and improve practice and ensure compliance with the regulations.

The manager was not a visible presence in the service and demonstrated a lack of knowledge with regards to the people living in the service and the systems in place. People and their relatives were unclear as to the management of the service.

There was an open culture amongst staff team members however staff were not sure they would be supported by management. Staff were not always clear on the visions and values of the provider organisation and did not feel involved in the overall development of the service.

Safe recruitment processes were in place and had been followed to ensure that staff were suitable for the role they had been appointed to prior to commencing work.

People were supported to make choices in relation to their food and drink and a varied menu was offered. People received support from health and medical professionals when required.

Staff were kind and caring. People's privacy and dignity was promoted throughout their care. People were provided with information regarding the services available.

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people using the service, their relatives, the staff supporting them and looking at records.

If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

We spoke with two people and the relatives of three people who lived at the home. People told us that they were happy with the care that they or their relative received. One person told us, "They do their best. I might be a bit miserable sometimes and they give me a little 'gee up' to be a bit happier. I have to keep drinking and they keep reminding me. They give me a glass and tell me when they will be back to make sure that I have drunk it."

The individual care plans we looked at were supported by detailed assessments that identified possible risks to people, such as their vulnerability to developing pressure sores, falls, nutrition, challenging behaviour and moving and handling.

The manager told us that they had formal authorisation for deprivation of liberty in respect of one person who had absconded from the home and had suffered a minor injury. However, they were aware that, following a recent court judgement, they needed to obtain this for all the people who lived in the home. This was because people could not freely move around the home, leave it or access the garden area without being accompanied by a member of staff for their own safety. The manager had arrangements in place to formally apply for official authorisation of this from the local authority for every person who lived in the home.

If medicines are stored at inappropriate temperatures they may lose their effectiveness. The temperatures of the room and refrigerator in which some medicines were store on the ground floor had not been checked on a number of occasions in the two months prior to our inspection. The temperatures for the room on the second floor had not been recorded for a period of three days and on five other occasions within the two month period. The provider could not be sure, therefore, that people's medicines had been stored appropriately and had retained their effectiveness for people.

We noted that in some bedrooms there were metal guards to the corners of walls to prevent them from being damaged. In some rooms these metal guards had smooth rounded edges but in other rooms the guards had a sharp edge. There was a risk of harm if a person fell onto one of the sharp edges. In one room we noted that the guard was missing and the decor was damaged. A flexible metal sheet was clearly visible and this presented a risk of injury should a person fall against it. The missing guard was replaced during the course of our inspection.

We looked at the records of the fire alarms tests which were due to be done by the maintenance staff member on a weekly basis. However, there were no records of tests completed for the period from 14 February 2014 to 14 March 2014. People may have been at risk if a fire had occurred during this period and the alarms had failed.

We saw that a review of the risks of Legionella had been completed by an external contractor on 29 March 2013. We noted that there had been three remedial actions requiring attention within three months of the date of the review. We also noted that these actions, as well as some requiring attention within a longer time span, had also been identified at the review undertaken by the external contractor in 2012. This indicated that the remedial actions had not been carried out following identification of the issues in 2012. There was also no indication that the remedial actions had been completed following the review of September 2013.

People's personal records including medical records were not always accurate and fit for purpose. We noted that, in one care record we looked at, information regarding a person's medication had been recorded in the communication record within the file. We also noted that, although the person's weight had increased and the settings for their pressure relieving mattress had been adjusted to reflect this, the care plan had not been updated to include the required settings. There was a risk, therefore, that a care worker could use the incorrect settings for the mattress. We also noted that their motivation had been assessed as poor but the care plan had been annotated that their motivation appeared to be good.

Other records relevant to the management of the services were not always accurate and fit for purpose. We noted that the maintenance staff member had recorded incorrect dates for when checks of the emergency lighting system had been carried out.

Is the service effective?

One person told us, "There are plenty of staff to help us. If I ask someone to help me there is always someone to do so." They went on to describe the care workers as, "...co-operative, hardworking...with a lot of common sense." One relative told us, "The carer's do a fantastic job." Another relative said, "The home is brilliant. The care staff are fantastic. [Relative] is happy here and can get out, which makes a difference." One relative told us, "On the whole the care is very good. I know [relative] is being looked after." Another relative said, "I have no problems. I know [relative] is being looked after."

Is the service caring?

We observed care workers as they interacted with people and assisted them to eat. The interactions were caring and respectful. People were gently assisted in their activities and encouraged to eat their meals. We saw that the care workers talked to people as they interacted with them. People appeared to be happy and we saw people laughing and joking with the care workers.

Is the service responsive?

One relative told us, "We have a relative's meeting every three months. We can voice what we need to. When we've said about things we notice changes and think 'oh yes they've taken that on board.' Last year people planted daffodils and tulips in the garden. We told the manager that they could not see them because of the bushes in the garden. These were removed so people could see [the flowers]."

We saw that the manager had invited people who lived at the home and their representatives to complete a questionnaire about the service in February 2014. This covered aspects of service such as the first impressions of it, the staff, communication, food service, the activities programme, the grounds and the standard of people's rooms. The majority of the responses were very positive. However 43% of people were less than satisfied with the grounds of the home. The manager told us that plans had been developed to change the gardens and we saw that these were displayed for the residents and their relatives to comment on.

Is the service well-led?

We saw that there were a number of quality audits undertaken by the manager and the quality manager. These included weekly audits of people's dependency and any pressure ulcer wounds as well as regular audits of individual care plans. We saw the record of the monthly environmental walk round completed by the quality manager in April 2014, although the action plan from this had not been completed at the time of our inspection. We saw that an action plan had been completed following the walk round in March 2014 and actions from this were ongoing.

We saw that people were provided with sufficient food and drink to meet their needs. A person who used the service said, 'The food is very good and there's plenty of it'. Another person said, 'The food here is tasty'.

We found the home had an effective system in place to reduce the risk and spread of infection. We noted that personal files were well organised and contained documentation which provided a clear audit trail. This demonstrated that appropriate checks had been undertaken before staff commenced employment.

We found that complaints were fully investigated and resolved where possible to the person's satisfaction.

We found that staff had been provided with training and opportunities to observe practices in the home to help them understand the impact of some practices on the people living at the service. Staff told us that they had found this very useful and they had experienced some of the care tasks for themselves. They felt that this had increased their understanding of the experiences of people who had dementia and how they might feel so they were now more considerate of this when supporting and assisting people.