Haven Rose Residential Care Home Limited

Updated 16 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. We did this to 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

One inspector and one Expert by Experience carried out this inspection.

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

Haven Rose Residential Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Haven Rose Residential Care Home is a care home without nursing care. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with CQC to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 18 January 2023. We visited the service on 18 and 23 January 2023.

What we did before the inspection

The provider was not asked to complete a Provider Information Return (PIR) as part of this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.

We reviewed information we had received about the service since the last inspection. This included notifications of events providers are required to tell us about, and information from members of the public about their experience of the service.

We used all this information to plan our inspection.

During the inspection

We spoke with 5 people and 4 relatives of people who used the service about their experience of the care provided. We spoke with the registered manager and 5 members of staff. We also received feedback from 2 professionals involved with the service.

We reviewed a range of records. This included 2 people's care records and multiple 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.

After the inspection

We continued to seek clarification from the registered manager to validate evidence found. We looked at records sent to us by the registered manager. These included training records and quality audits.

Updated 16 March 2023

About the service

Haven Rose Residential Care Home is a residential care home providing personal care and accommodation for up to 16 people. The service provides support to older people and those who may be living with dementia or a mental health condition. At the time of our inspection there were 11 people using the service. Accommodation was spread over three floors accessible via stairs.

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

People told us they were happy and safe living at Haven Rose Residential Care Home. We were told by people living in the service and their relatives that they felt included, safe and well cared for. Although the service was clean, ongoing refurbishment was still in progress. Risks related to legionella had not been fully mitigated.

Risks to individuals were assessed when they moved into the service, reviewed by the registered manager and reflective of their current needs. The registered manager worked well with other healthcare professionals to ensure that learning took place and necessary changes were made to continually improve.

People were supported safely and appropriately by sufficient staff who knew people well. However, not all staff had full work history with gaps explained. Staff training was not always complete or up to date although we did not observe any evidence of poor care during the inspection.

Processes and procedures were in place to store and administer medicines safely. We were somewhat assured appropriate infection prevention and control measures were in place to protect people against the risk of COVID-19 and other infections.

The registered manager did not have 1 to 1 meetings or appraisals with staff although due to the size of the home they were in regular contact with staff. The staff team told us they felt supported by the registered manager. People who used the service and other stakeholders were involved in how the service was managed. The registered manager had processes in place to monitor and improve the quality of the service people received and had been well supported by local authority quality teams.

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 10 May 2019).

Why we inspected

This inspection was prompted by a review of the information we held about the service.

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.

This report only covers our findings in relation to the key questions safe and well-led. 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. This is based on the findings at this inspection.

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

Enforcement

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 breaches of regulation in relation to managing the risk of legionella, staff recruitment practice and training at this inspection. We found the two areas reviewed were now rated as requires improvement.

Follow up

We have requested 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.