About the service:

Rosehill Rest Home is a residential home registered with the Care Quality Commission (CQC) to provide personal care for up to 17 older people.

At the time of the inspection, there were four privately funded people living at the service. A fifth person was in hospital.

People’s experience of using this service:

Systems and processes to monitor the service were not effective and did not identify areas for improvement, together with poor oversight of the service. There was a management team who did not have clear lines of responsibility or a shared vision of how to improve the service. The statement of purpose, along with the vision and values of the care to be delivered, was not clear within the management team.

Although staff were aware of some risks, other risks were not monitored, recorded or managed effectively. This put people at continued risk of avoidable harm. Accidents and falls were not monitored to identify any trends or patterns.

The requirements of the Mental Capacity Act 2005 (MCA) were not adhered to and mental capacity assessments and Deprivation of Liberty Safeguards were not always completed as necessary.

The provider had not ensured any prospective staff underwent a robust recruitment process to ensure they were safe to work with vulnerable people.

The provider did not notify the Care Quality Commission (CQC) of all incidents or accidents which affected people.

People had care plans in place. Whilst these contained pertinent information, they did not always reflect people’s current needs, contain the right information and were duplicated in places.

People were cared for in a respectful, kind and caring way. Staff had built up relationships and knew people well. People were relaxed and were comfortable with staff.

People received a varied diet which reflected their choices on the meals served. People had access to snacks and drinks throughout the 24 hours.

People received their medicines safely and on time.

Some activities took place in the home, but these were limited and based in group settings which did not reflect people’s individualised hobbies or interests.

The home was kept clean and was homely and welcoming in appearance.

Rating at last inspection:

At the last inspection in November 2018 the service was rated as inadequate in safe, effective, responsive and well led. It required improvement in caring. The overall rating was inadequate.

Why we inspected:

This comprehensive inspection was scheduled based on the previous rating. We received an action plan following the previous inspection. However, this did not address all the improvements required and timescales for completion.

Enforcement:

At the last inspection in November 2018, six breaches of regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009 were found.

Following the last comprehensive inspection in November 2018, the service was placed in special measures by the CQC. The purpose of special measures is to:

• Ensure providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made

• Provide a clear timeframe within which providers must improve the quality of care they provide, or we will seek to take further action, for example to cancel their registration.

The service was placed in whole service safeguarding by Devon County Council (DCC) on 2 November 2018. As a result of persistent contractual default, DCC also cancelled their commissioning contract with Rosehill Rest Home in January 2019; they no longer place state funded people at this service. The provider placed a voluntary suspension on admitting any further privately funded people to the service. This was still in place at the time of th

This comprehensive inspection took place on 5, 7 and 12 November 2018. It was unannounced on the first day. This inspection was brought forward due to risk following concerns shared with us from the local authority safeguarding team. This was with regarding to poor practice and poor management at the service.

Rosehill Rest Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premised and the care provided, and both were looked at during this inspection.

Rosehill Rest Home accommodates up to 17 people in one adapted building over three floors. There is a stairlift giving access to all three floors. There were 13 people living at the service when we carried out the inspection.

The provider was also the registered manager. A registered manager is a person who has registered with the CQC 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 the last focussed inspection in February 2017, there were two joint registered managers in post. Following that inspection, one of the joint registered managers applied to the CQC to voluntary deregister from this post. The provider remained the one registered manager in post.

At the time of this report, the local authority safeguarding team were continuing to investigate concerns raised. As a result of the concerns, the home was in ‘whole home safeguarding’ and there was a restriction on admissions to the home.

The service was not well led. There was no management structure in place and staff did not have clear lines of responsibility. The provider was being helped to run the service by the senior care worker. However, they did not have the skills or knowledge to undertake this role without further training.

There was a clear lack of governance in place, together with a lack of the necessary record keeping pertaining to the running of the service. There were record deficits in all areas and these records were either unavailable, could not be found or were not in place. The provider was aware of this and knew this was an area for improvement. Some of the records relating to the running of the business had had not been completed ort updated since 2016.

People did not receive individualised care suitable to their individual needs. Some of the care practices at the service were old fashioned and out of date. There was a lack of understanding of person centred care. Three people living at the home had not had a care plan in place since they came to live at the service. Other people did have a care plan but these were incomplete and the information held within them outdated.

Staff did not always treat and speak to people in a way which showed privacy, dignity and respect. Some practices at the service were old fashioned and contained ‘unwritten rules’ which impacted on people’s daily lives and choices.

Risks to people’s health, care and welfare were not identified and systems not put in place to reduce these risks. These included risks to people’s nutrition, skin pressure damage, safe moving and handling, environment and falls.

People were nursed in specialised beds and some people had bed rails in place. This equipment was not regularly monitored and checked to make sure they were at the correct settings for the people’s weights and were in good working order.

People had their weights monitored but these were not reviewed and appropriate referrals made where people had lost weight.

People did not receive their medicines in a consistently safe way. This meant we could not be sure people had received their right medicines, at the right dosage and at the right time.

Accidents and incidents were recorded and filed by staff. However, these report

We carried out an unannounced comprehensive inspection of this service on 7 and 13 June 2016. The service was judged to be overall good but required improvement in the effective section. A breach of regulation was found. This related to not adhering to the principles of the Mental Capacity Act 2005 (MCA), not ensuring staff were adequately trained in this area and depriving people of their liberty without lawful authority. A statutory requirement notice was issued. The provider did not send an action plan to the Care Quality Commission (CQC) as to how they would meet this requirement. CQC followed this up and an action plan was received on 12 December 2016.

After that inspection we received concerns in relation to poor care practice, people being restricted in the home and poor cleanliness of the home. The concerns were also reported to the local authority safeguarding team by the CQC. CQC undertook a focussed inspection. This report only covers our findings in relation to this. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Rosehill Rest Home on our website at www.cqc.org.uk.

We carried out this unannounced focussed inspection on 23 November at 8.10pm and 5 December 2016 at 11am. This was to observe practice at different times of the day.

Rosehill Rest Home is registered to provide accommodation and personal care for up to 17 older people, including those people living with dementia. There were 13 people living at the home at the time of our visits.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 registered manager was also the provider. They planned to retire as registered manager in the near future. An application had been received by CQC from the deputy manager to become the registered manager.

On our first visit, two people were in the lounge watching television and the rest of the people were in their bedrooms. Two care staff were assisting people to go to bed. There was a calm and restful atmosphere at the service. People were reading, watching television or relaxing in their bedrooms. People we spoke with told us they could go to bed when they wanted but liked to retire to their bedrooms at certain times.

We looked at people’s care records so see if the service was acting in accordance with the Mental Capacity Act 2005 (MCA). Some people had bedrails in place to reduce the risk of them falling out of bed. We looked at whether these were being properly used and recorded.

During this inspection we found people were not being restricted, care practice was satisfactory and the home was very clean. On our first visit we found gaps in record keeping in people’s care files. These were in relation to consent, mental capacity assessments and best interests decisions. On our second visit appropriate action had been taken and records updated.

The local authority safeguarding team carried out a full investigation into the concerns raised. No further action was taken.

The provider now met the breach of regulation. However, improvement is still required. The provider had not been proactive in ensuring records were kept up to date until our second visit when they were in place. These records need to be in place consistently in each person’s care file in accordance with the Mental Capacity Act 2005.

This inspection took place over two days on 7 and 13 June 2016 and was unannounced on the first visit. The second visit took place in agreement with the service.

Rosehill Rest Home is registered to provide accommodation and personal care for up to 17 older people, including people living with dementia. There were 17 people living there on both our visits.

The last comprehensive inspection took place on 9 and 15 June 2015. Six breaches of regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were found. This was because: risk assessments were not in place; medicines were not managed safely; people’s rights under the Mental Capacity Act (2005) had not been adhered to; the correct procedures to deprive people of their liberty had not been followed; staff had not received the necessary training; people did not receive planned person centred care, and systems to monitor and improve the service were not in place. You can read the report by selecting the ‘all reports’ link for Rosehill Rest Home on our website at www.cqc.org.uk.

After the last comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches of regulation. According to the action plan, all breaches of regulation would be met by 28 August 2015.

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

The service had a registered manager who was also the registered provider. 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 lived in a family run home where they were relaxed and comfortable. The atmosphere was homely and friendly and people and relatives felt safe. Relatives said, “People are happy … it’s very nice … people are treated with respect … all the people are looked after … it’s very small and it’s like a proper ‘home’, it’s full of knick-knacks and I am very impressed with them” and “(My relative) is content and happy and that is all you can ask for.”

Staff knew people well and cared for them as individuals. Two people said, “Staff are very kind … they are very good” and “I am looked after.” People received care suitable for their needs and with enough staff on duty. Staff were safely recruited, trained and enjoyed their work. Staff said, “I absolutely love my job here … I never want to change … we all pull together to look after residents … they get what they need day or night” and “It’s lovely here because it is family run … I look after people properly just as I would if it were my mum and dad.”

Two people said, “I feel safe here … I am well looked after” and “I’m happy here … it’s very good.”

Staff felt supported by management and felt part of a team. They had a good understanding of safeguarding and knew how to recognise the different types of abuse. They knew the correct action to take and who to report any concerns to.

For those people who lacked capacity and were unable to give consent, the Mental Capacity Act 2005 (MCA) had not been followed. People had not had a mental capacity assessment undertaken and ‘best interest decisions’ had not always been carried out in accordance with the MCA. However, applications had been made appropriately to the local authority Deprivation of Liberty Safeguards team for those people who need to be deprived of their liberty.

Each person had a care plan with suitable risk assessments in place. Care plans included key information and were up to date. Health and social care professionals were involved in people’s care and their advice acted upon. Good working relationships had been developed with the local GP surgery who were very complimentary of

When we visited Rosehill we spoke with six people who lived there and were able to observe eight others in the lounge and in the dining room. We spoke with the registered manager and four staff on duty and a health and social care professional who had visited the home.

We looked at risk assessments, care plans and care records. We found that people’s needs had been assessed individually and staff were well informed so they knew how to support people.

People told us they were able to get staff attention when they needed and that the providers were available if they wished to speak with them. We saw that people were calm and contented in their daily life. We saw staff treating people with dignity and asking them when they wanted to move, for example when it was time to go for lunch.

A professional who had visited the home told us they had observed that staff found out what people liked to do, and arranged for them to be involved in activities that were meaningful for them.

When we visited Rosehill Rest Home we met with seven people who lived there in their private rooms or in the lounge or dining room and were able to observe others. We met two visiting relatives and spoke with two health and social care professionals who had worked with the home. We met the registered manager, four staff on duty and looked at care records and other documents relating to the running of the home.

People told us they liked living at Rosehill Rest Home. “I’m very pleased with what I have here,” one person told us. Another who had not lived at Rosehill Rest Home for very long told us, “You begin to feel that people like you – that makes all the difference.”

Staff made time to get to know the people they cared for and were able to provide individual attention.

We found that the registered manager had admitted one person to the home without assessing their needs or whether the home was suitable for meeting their needs. This placed them at potential risk of harm. It also meant that staff had no information about how they preferred their care to be provided.

We found that the house was clean and hygienic throughout and that good systems were in place to protect people from the risk of cross infections.

Measures were taken to ensure that suitable people were employed to work in the home.

The quality of the service provided was monitored and maintained by regular attention from the service providers.

When we visited this home, we met with nine people living there and were able to observe others in the lounge and dining room. We met with two regular visitors to the home and a healthcare professional. We met with three staff on duty and the providers of the service, one of whom was the registered manager.

One person told us, “Overall, the food is good. I am confident that will like what is brought – I have never sent anything back. It is fresh home cooking.”

They had a call bell attached to their chair so that they could reach it easily through the day. "They come quickly when I ring it,” they told us. Another person who lived at the home said, “I am well cared for. The staff help me if I need to go to my room” and another told us that staff helped them to wash and dress in the way that they liked.

A health care professional who had visited regularly said that staff at Rosehill Rest Home had called for assistance appropriately on behalf of people living in the home, and followed nurses' guidance. They said it was, “Always lovely and warm here, and smells nice.”

We found that the staff were competent and caring. We saw staff helping people sensitively at mealtimes, giving time and encouragement to people to eat their food.

We found that some assessments of risk needed to be updated to make sure people would be cared for in a safe way, and some of the arrangements for providing care did not protect people well enough against potential risks of cross infection.

We brought forward this planned review of compliance as a result of some information of concern we received from an anonymous source. This centred on individuals not being able to have their drinks anywhere other than the dining room and bedroom doors being kept locked.

We carried out an unannounced inspection to this service on 12 January 2012. We spent six hours at the home and spoke with eight people who live there, and to seven staff members including the owner/manager of the home. We also spent some time looking at key records including care plans, pre admission assessments, staff recruitment and training files and information relating to quality assurance systems within the home.

People we talked with spoke very highly about the care and support they received comments included –

• ‘’we get excellent care here, I am off my food but its not their fault, the food is good’’

• ‘’I don’t want to go home, I am happy to stay here now’’

• ‘’the staff are all lovely, this is the best place and I would not want to go anywhere else.’’

One visiting relative confirmed that they visited the home frequently and found that in their view staff ‘’paid a great deal of attention to peoples needs and the care was very good.’’

We spoke with the registered manager/owner of the service who confirmed that they do only serve drinks in the dining area or in peoples own bedrooms. She said that the reason for this was two fold, it encouraged people to keep mobile and it meant that people were not at risk of tripping on small table or spilling their drinks. We discussed the fact that this was peoples home and their right to have a drink where they wished. We were told that this decision had been discussed with current people living in the home, who were all in agreement with this house rule. We asked how this would affect any newer people coming to the service if they wanted to have their drink served to them in the conservatory. The registered manager/owner said that she believed this was the right decision to keep people safe and to continue to encourage their mobility. We have asked that they make this clear in their service user guide and statement of purpose. These are documents given to new people thinking about coming to the service to help them decide if it is the right home for them.

We saw that staff worked with people in a way that showed respect and regard of people’s dignity and privacy. Staff had a good understanding of the needs of people they cared and supported, and we observed a good rapport between them.

We spoke with staff and heard that they had good support and training to do their job effectively. We also saw that recruitment processes were robust. This meant that vulnerable people were being protected from unsuitable people being employed.

We saw that the home had processes in place to review and monitor the quality of care and that peoples views were listened to.

Rosehill Rest Home is registered to provide accommodation for up to 17 older people who require personal care. We carried out an unannounced comprehensive inspection over two days on 9 and 15 June 2015

Prior to this inspection, this service had been inspected on 21 June 2013. This found the provider was not meeting the standard required in relation to the care and welfare of people. A follow-up inspection was carried out on 25 October 2013 which found the provider met the standard required.

There was a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements of the HSCA and associated regulations about how the service is run. The registered manager at Rosehill is also the provider.

Management and staff had limited understanding of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards. Where people lacked capacity, staff did not understand the law which underpinned people’s rights and the appropriate actions had not been taken.

People had some assessments of risk and plans of care in place. However, these were not accurate and up to date; they did not fully reflect the care and support people were receiving. More information was needed to guide staff how to meet people’s needs in a consistent way.

Improvements were needed to ensure people received their right medicines at the right time.

Not all the necessary pre-employment checks had been carried out before staff began working at the service. There were sufficient numbers of staff on duty, but not all staff had received the training required to do their jobs safely. People enjoyed their food and had a choice of meal.

There were some systems in place for regularly monitoring the quality of the service, but these audits had not picked up the shortfalls in record keeping.

There was a homely, calm and unhurried atmosphere at Rosehill on our visits. Many of the people had lived there for many years. They told us they were happy, it was ‘home from home’ and they had choices in their everyday lives. People were treated with privacy, dignity and respect by kind, caring and compassionate staff who knew people well. They enjoyed the food served. People were confident they would be listened to if they had any concerns.

People, their relatives and health care professionals spoken with were complimentary about the care and support provided. Relatives felt welcomed by staff.

Staff felt valued, supported and part of a team. Many of the staff team had worked at the home for several years, but the provider had recruited some new staff to join the team. They had confidence in the management team who worked alongside them.

We found six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we told the provider to take at the back of the full version of this report.