Rose Cottage Nursing Home

There was an active learning culture at the service where incidents and accidents had been clearly recorded, investigated with clear outcomes and actions implemented to prevent reoccurrence. This had improved since the last assessment of the service.

People were safeguarded from the risk of abuse, and leaders reported concerns to relevant statutory authorities when required.

Staff were recruited safely and had received training relevant to their roles which showed an improvement since the last assessment.

Safe systems were in place to support people when moving between services. People’s needs were assessed on a regular basis. We observed people to be clean, well-presented and appropriately dressed. People’s bedrooms contained personal belonging, which were important to them, creating a homely environment.

There were regular opportunities for people, relatives and professionals to provide feedback on their care and experiences of living at the service. There was a shared culture within the service, with leaders and staff demonstrating commitment to ensure people had their needs met. There was a consistent team of staff with no agency workers used. Staff felt able to speak up about any concerns they had and felt treated fairly by leaders.

People had care plans in place which reflected their future wishes and end-of-life preferences.

External professionals spoke positively about the management of the service. They told us the service worked collaboratively with healthcare professionals to support people’s needs and described communication as effective. Professionals also commented that staff knew the people they supported well.

However, we identified shortfalls relating to the safety of the environment. Risks were identified within communal areas which had the potential to cause harm to people. This included doors which contained chemicals not being locked so people could gain access and nails sticking out of a radiator cover.

Information relating to fire evacuation procedures was not consistent across records, resulting in conflicting guidance for staff. In addition, the business continuity plan (BCP) did not accurately reflect the people living at the service, as some current residents had not been included and some people who no longer lived at the service remained listed.

We also observed infection prevention and control (IPC) practices that did not always effectively mitigate risks to people.

Risks associated with oxygen use and choking were not always documented appropriately.

Although the registered manager took immediate action to address these issues during the assessment, they had not been identified through the service’s governance systems. Therefore, it was unclear whether these concerns would have been recognised and addressed without the Care Quality Commission’s (CQC) involvement.

In addition, we observed occasions where people’s dignity was not consistently maintained during medicines administration and when a person became unwell. Medicines practices were not always in line with best practice guidance.

The registered manager acknowledged our feedback and developed an action plan to address these concerns.

We identified two breaches of the legal requirement in relation to safe care and treatment and governance.

We have asked the provider for an action plan in response to the concerns found at this assessment.