Rosemount Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The service has been rated inadequate. We found 6 breaches relating to Need for consent, Infection Control Issues, Medicines, Equipment, Premises, Assessment of risk, Good governance, Staffing, Fit and proper persons employed and Duty of Candour. Medicine care plans were not always sufficiently detailed or up to date. There were enough staff to meet people’s day today needs however they had not been sufficiently supported by the provider. We found issues with the cleanliness of the environment and problems with the equipment in use within the home.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were not always satisfied with their care and support. Relatives expressed concerns around whether the care met people’s needs. Relatives were unclear about whether the management and staff understood the contributory factors to falls in order to learn from them. People raised concerns around not knowing about their care plan. However, spoke positively about changes they had seen since the new manager has been recruited. People told us that she was present in the home, conducted walk arounds and was making a difference. Residents’ and relatives’ meetings had been implemented in the home and were taking place on a monthly basis.

The provider acknowledged that historically, there had been some issues with acting on concerns and identifying learning. They assured us that the new manager was embedding processes to ensure concerns were responded to and that lessons were learnt from incidents. Staff told us they felt the new manager was approachable and felt she was supportive of the staff learning from concerns.

The provider had systems in place to document any complaints and compliments received. However, some of the issues raised in these complaints were still ongoing and we were not assured that adequate learning had taken place as a result. Notifiable safety incidents had been identified, however, there were no records confirming Duty of Candour processes had been followed. These incidents had occurred prior to the commencement of the new manager’s employment.

Overall, people and their relatives felt that transitions were managed well at Rosemount Care Home. We spoke to one person who was in the process of moving from Rosemount Care Home into Independent Supported Living due to improvements in his physical and emotional wellbeing during his stay. He spoke positively about support from the new manager and transition arrangements to support him during this time.

The new manager explained that she had strengthened the admission process since she had come into the home and was conducting all pre-admission assessments so she had clinical oversight. She told us, “We are looking at the skill mix of staff and not just the needs of person.” Staff were aware of people’s needs. The registered provider acknowledged that further work was required in relation to care records and this had commenced during the assessment.

At the time of the assessment, the service was in organisational safeguarding. This is a multi-agency process to ensure organisations are run in a way that actively prevents harm, harassment, abuse and neglect. At the time of the assessment, there was a voluntary suspension on nursing admissions in place and only one residential admission was allowed per week however, since then this has been lifted. Partners shared concerns in relation to safe systems and commented that whilst the home was open to working with partners, they were ongoing concerns about the providers ability to sustain safe systems of care even with the support, advice and guidance of numerous professionals.

Historically, systems, pathways, and transition planning had not been effectively established and embedded into practice. Care plans, particularly those on the nursing unit, were not always detailed or accurate which impacted on aspects of their clinical care. However, the new manager had completed some work to strengthen these processes and the home was in the process of transferring care plans onto a new electronic care management system. The service had an admissions policy in place. We reviewed the pre-admission assessment paperwork for a person admitted to the residential unit. The assessment gave a sufficient overview of his needs.

Overall, people and their relatives felt they were safe at Rosemount Care Home. However, some relatives felt falls and medicines management presented a risk to people living there. People told us they had raised concerns or queries about their care. However, the assessment evidenced their feedback was not consistently acted upon. People and their relatives did tell us they felt the new manager provided better support since coming into her role.

Where people raised concerns directly with us, we spoke with the new manager who took immediate action and spoke with the people involved. They then advised us of action she had taken. Another staff member told us, “We always report anything to the senior staff.”

We observed staff supporting people and did not see any concerns in relation to staff behaviour.

The provider has a safeguarding policy in place, as well as a Public Interest Disclosure policy to support with whistleblowing. They had safeguarding systems in place. Staff said they had training and a good understanding of what to do to make sure people were protected from harm or abuse.

People were not always involved in the management of risk. There was limited evidence that demonstrated people and their relatives had been involved in the assessment and management of risks, or in care plan reviews. However, family members told us that they had seen an improvement since the new manager came into post. One family member told us, “Now the new manager has started, and she is far more energetic and keen to get problems resolved and sorted. Changes are slow and incremental but feeling better, they are coming to do essential checks.”

Since her appointment, the new manager was working with the team across the home to identify gaps in the service, areas for improvement and how to address them. The new manager told us that they held ‘residents and relatives‘ meetings where risks were discussed.

We observed concerns relating to the management of risk including medicines, catheter care, wound care, the use of equipment, nutrition and hydration, diabetes care and mobility needs. We passed these concerns to the new manager to review and address.

A process to involve people, and their relatives in the assessment and management of risks had not been fully implemented. Care records did not always evidence that people and their relatives were included in reviews or specific decisions under the Mental Capacity Act. Risks to people’s health and wellbeing had not been appropriately assessed and strategies had not always been put in place to minimise risks.

People gave us mixed feedback about the environment at Rosemount. Some people and their relatives told us they did not feel the environment at Rosemount was always safe. One person told us that their broken bed rail had not been responded to in a timely manner, leaving them at risk of harm. We raised this with the manager at the time of the assessment and we received assurances that this had been fixed after the onsite visits concluded. However, another relative told us, “The home is beautiful.”

Several staff told us they had concerns regarding the environment within the home. One staff member told us, “The building is in a state of poor repair. If you look at bedroom windows and bathroom areas that is clearly evident.” Staff told us there had recently been a period of time were there was no hot water in the kitchen as the boiler was broken. Staff told us that similar concerns regarding the hot water had been identified in the laundry room. The new manager explained that this had been addressed and was fixed.

Potential risks in the environment were noted during the assessment including the activities cupboard and sluice were unlocked on occasions leaving people at risk of exposure to hazardous materials without adequate supervision. We raised these concerns with the new manager who told us this had been addressed.

Systems and processes had not been fully implemented to detect and control potential risks in the environment. Daily cleaning schedules demonstrated that signatures were missing on several dates, and for several areas of the home including bathrooms, toilets and people’s bedrooms. Relevant servicing of equipment had been completed. There was limited evidence that audits had been used effectively to detect and control potential risks in the environment, however, environmental improvements were detailed on an action plan from the local NHS Trust’s IPC team and the new manager had started work to address some of these issues.

Overall, people and their relatives did not feel there were enough staff in Rosemount Care Home. They told us they were particularly concerned about the provision of staff in the home at night and were concerned this led to an increased risk of accidents. We also received feedback about the lack of staff to provide activities in the home. One person told us, “There are no activities at the weekend…there’s no one to organise them.” The new manager told us a second activities coordinator had been recruited.

Staff had mixed views about staffing levels, with some commenting there were not enough staff and others saying staffing levels were adequate. One staff member told us, “Staffing levels are poor. I have seen residents having to wait inordinate amounts of time for basic needs i.e. toilet.” Another staff member told us that whilst there had been issues with staffing levels, recruitment had taken place in the last few months to fill most vacant positions. Some staff felt they were supported by management, and this had improved recently. One staff member told us, “I have regular appraisal and feedback sessions and this has been very helpful.” Training and competencies checks had not been carried out as planned prior to the new manager being appointed. The new manager told us that this was being addressed and further training and competency checks were being carried out.

During our site visits, we observed there were enough staff to meet peoples needs. However, we identified shortfalls regarding staff practices in relation to catheter care, specialist feeding techniques, wound management, the management of medicines and MCA and consent. The new manager was aware of these issues and was working to address them.

Recruitment records did not always show that safe recruitment procedures were followed. Supervision, appraisals and training had not been carried out as planned to ensure staff were skilled. The new manager acknowledged this and had taken some initial steps to rectify these issues.

People noted some improvements in the cleanliness of the home. One person told us, “It’s cleaner now than it used to be, it used to smell but it doesn’t now.” Another told us, “[Person’s] carpet was disgusting and now he has a new one.”

Staff told us that it was difficult to keep the home clean. One staff member told us that one person’s bathroom was so overfull with equipment and materials they couldn’t get in to clean it properly. Staff told us the domestic team were often understaffed due to sickness or were redirected to support other areas such as the laundry which meant, sometimes, they were unable to fully clean the home. However, this was addressed with the new manager who confirmed domestic staffing had not been affected. Staff told us there were ongoing issues with a lack of paper towels. Paper towels were delivered on the second day of the assessment, however, some of these were left on the top of toilet cisterns.

Not all areas of the home were clean. There were areas of damage to a lot of the communal woodwork areas including door frames which meant these areas were more difficult to clean. Sinks, toilets and equipment were not always clean and well maintained. The sluice room contained no PPE such as gloves/aprons, the sink was unclean and there was mould around the taps/splash back area. There were stored towels in a communal bathroom which posed a risk of cross infection. The new manager explained that these issues had been addressed and poorly maintained equipment had been disposed of and all areas cleaned.

The provider had an Infection Prevention and Control (IPC) Policy in place. Audits were in place but did not always identify shortfalls.

Some people and their relatives expressed concerns about the management of medications in the home. Whilst some people and their relatives told us they were kept up to date about medication changes, others told us they did not receive communication and did not know what was happening with medications.

The new manager explained that new processes were being implemented and that staff were learning the new system however, this was a “work in progress.” The new manager listened to our feedback and told us that the issues identified had been addressed.

An effective system was not in place to manage medicines. Processes to manage topical medicines were not always robust, and records were not always in place to guide staff on how to apply these and record applications. Records were not always up to date with core information. For example, there was inconsistent recording of allergies. Protocols for ‘when required’ medications were in place for the majority of people living in the home. However, we found they did not always match up with prescribed instructions. Temperature monitoring was taking place. However, recordings demonstrated they were not in line with the recommended ranges, therefore we had no assurance medicines were being stored appropriately. Processes were not always robust for supporting people that needed their medicines to be given covertly, (hidden in food or drink). There was no process in place to record the administration of thickener to food and fluids for people with swallowing difficulties. Audits were taking place. However, they had not identified all issues we found whilst on assessment. Following our feedback, the new manager told us that these issues had been addressed.