Dora Rose Care Home

Updated 8 March 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by two inspectors. An Expert by Experience was used to telephone relatives. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Dora Rose is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement dependent on their registration with us. Dora Rose is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. A new manager had been in post for five months and had applied to register. We are currently assessing this application.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 4 people who used the service and 9 relatives about their experience of the care provided. We spoke with 16 members of staff including the manager, clinical lead, nurses, senior care workers, care workers, cook, administration staff and activities coordinator. We received feedback from 1 visiting professional.

We reviewed a range of records. This included 6 people's care records and multiple people's medication records. We looked at 3 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including audits and policies and procedures were reviewed.

Updated 8 March 2023

About the service

Dora Rose is a residential care home providing personal and nursing care to up to 71 people. The service provides support to older people, including people living with dementia, people with physical disabilities and younger adults. At the time of our inspection there were 62 people using the service.

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

During the last inspection, quality assurance processes were identified as requiring improvement. This inspection has found improvements are still required to ensure risks are effectively monitored and care documentation is kept current and in accordance to peoples changing needs.

Risks to people were not always managed or monitored safely. There were gaps in care monitoring recordings and medicines were not always effectively monitored or managed.

The provider acted quickly to the recommendations identified and took action to improve quality monitoring systems. They updated care documentation and improved processes to manage medicines safely. These will be reviewed on the next inspection.

Staff used personal protective equipment (PPE) effectively and received infection prevention control training.

There were enough staff on duty to support people's needs and staff were recruited safely.

People, relatives and staff were confident to raise concerns or complaints and told us they felt these would be listen to and acted upon.

Relatives and staff had confidence in the manager's ability to lead the service. They confirmed how the provider works in partnership to achieve positive outcomes for people.

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

The last rating for this service was good (published 21 October 2021)

Why we inspected

We received concerns relating to safe monitoring and recording of people’s care. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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

We have found evidence that the provider needs to make improvements. Please see the Safe, and Well-Led sections of this full report.

The provider acted during and after the inspection to mitigate the risks identified.

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

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified a breach in relation to the quality monitoring systems at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.