• Care Home
  • Care home

Rosclare Residential Home Limited

Overall: Good read more about inspection ratings

335 Ewell Road, Surbiton, Surrey, KT6 7BZ (020) 8390 4183

Provided and run by:
Rosclare Residential Home Limited

Important: The provider of this service has requested a review of one or more of the ratings.

Report from 16 May 2024 assessment

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Well-led

Good

Updated 17 July 2024

A new registered manager was in post who provided clear leadership and oversight at the service. There was a clear management structure in place and staff were aware of their roles and responsibilities. Staff felt their wellbeing was supported by the registered manager. They felt comfortable approaching the registered manager and felt able to speak up if they needed to. Governance systems had been improved to ensure there was regular review of the quality and safety of care provision. There had been a number of improvements made since the last assessment and there was a commitment within the staff team to continue to learn and improve practice. However, we found there were some areas of service delivery that continued to require improvement, notably the level of detail captured within people’s care records and activities provision. The registered manager took on board this feedback and would make the necessary improvements to address the shortfall.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Shared direction and culture

Score: 3

Staff had a shared vision which embraced change and delivering improvements. The registered manager told us, “I strongly believe in having a relaxed and positive atmosphere at the service, staff speaking freely and sharing concerns. I take concerns positively aiming to improve. We work as a team here.” Staff told us there was an open-door policy which encouraged them to have open and honest conversations with the management team.

There was a clear vision for the direction of the service which was aimed at people achieving the best outcomes possible. Changes to people's care needs were recognised easily because of the good leadership at the service and processes in place to support team working. The service took part in multi-disciplinary meetings advocating on people’s behalf and in their best interests, for example if it was safe for a person to go back to living in their own home.

Capable, compassionate and inclusive leaders

Score: 3

The management team were available for support and communicated changes to the staff team well. Staff’s comments included, “Yes, [the registered manager] listens. Any good suggestions she accepts. We are improving together with the managers. We are a team. Before we didn’t know what was going on upstairs. Now they are discussing things with us and telling us what is going to happen. They try to do their best and I really appreciate it.” The management team used different resources to stay up to date with legal requirements. Any practice updates necessary were shared with the staff team to ensure good care delivery for people.

Processes were in place to share roles and responsibilities. The management team told us that delegation of tasks was important at the service as it empowered staff to develop skills and take accountability for their actions. Staff were upskilled and took a lead on certain aspects of service delivery, including overseeing infection control procedures, medicines management and oral hygiene at the service. The new registered manager was aware of their responsibilities and the service now adhered to the requirements of their CQC registration, including the submission of statutory notifications about key events that occurred at the service.

Freedom to speak up

Score: 3

Staff knew how to whistleblow and felt confident to do so. Their comments included, “I know what whistleblowing is, it's about telling your concerns to others. I would do that. I feel safe here. I would go to the professionals; I would go to you [pointing at the CQC inspector]” and “We have a notice board [with information about when and how to report]. We record and report to the local authority, for example.”

Staff’s feedback was encouraged so that team working could be improved as necessary. This included actions being taken to support information sharing and communication as suggested by staff in the most recent ‘Staff survey’. Staff had access to the updated provider’s ‘Whistleblowing policy’ for guidance on the actions to take should they need to report their concerns externally.

Workforce equality, diversity and inclusion

Score: 3

There was an acknowledgement and appreciation to staff for the work they do. The registered manager told us how they promoted staff’s wellbeing which supported their performance. This included staff being praised for their efforts and encouraged to highlight each other’s good work.

Processes were in place to support staff’s development and flexible working. Staff’s shift requests and short time notices such as medical appointments were accommodated to promote their life choices and healthy work life balance.

Governance, management and sustainability

Score: 3

Staff told us there were effective systems in place to ensure good communication amongst the staff team, which promoted team working and ensure continuity of care. Staff discussed tasks during the shift handover and a communication book was used by the staff team to pass on information to each other when needed, including monitoring upcoming hospital appointments.

Improvements had been made to quality assurance processes making sure the care provided for people was safe and effective. There was a regular programme of audits undertaken by the registered manager and senior staff to review the quality of service delivery. This included reviewing the safety and effectiveness of care delivery, care records, staffing arrangements, and medicines management arrangements. Key performance data was also regularly reviewed to inform service delivery, including review of incidents, accidents and complaints.

Partnerships and communities

Score: 3

People, and those important to them, were encouraged to raise concerns which were resolved by the provider as necessary. Managers were approachable and visible in the service. Although not all people knew who the managers were, they felt comfortable to express their concerns to the staff team if needed. A family member told us, “I do know the manager and I would say she is approachable. I would probably talk to the assistant manager if there was a problem, she is very nice and definitely approachable.”

Involvement with the community was important to the provider and included contacts with the local school, church and library. People were supported to go to the community hall for afternoon tea to socialise and build relationships with the locals.

Health and social care professionals felt there was good partnership working. They felt able to speak openly and honestly with the staff team. They were asked for their feedback about the service and their suggestions were listened to and acted upon.

Systems were in place to ensure that complaints received would be addressed appropriately. The service had not received any formal complaints in the last 12 months. Family members were asked to complete a survey for their feedback about the care being provided to their relatives. Results of the survey were mainly positive, and suggestions made by the family members were addressed by the provider, including replacement of furniture where it was necessary.

Learning, improvement and innovation

Score: 3

Staff were focused on learning and professional development. One staff member told us, “During the supervision they are giving us targets and goals on how to improve.” Staff also focused on how to improve outcomes for people and told us the management team recognised and acted upon their feedback. This included supporting a person to move to a different room which could better accommodate their needs.

There was good management oversight of the service which focused on keeping people safe. The new governance processes in place had enabled a number of improvements to be undertaken at the service and to continue to learn and develop. However, we found some of these systems were not always effective and we continued to find that some records lacked detail, particularly regarding risk management and mental capacity decisions, and the provision of activities to ensure people were adequately engaged and stimulated. The provider was keen to improve the service where we recognised shortfalls. They listened to our feedback and where possible took prompt action to address any concerns identified during this assessment.