He care hogar, which supports adults living with dementia and people with physical disabilities, remained at its current overall rating of ‘requires improvement’.
Rose Cottage received ‘improvement required’ ratings for all three focus questions on safety, leadership and effectiveness.
The inspection was triggered by the deaths of two patients in separate incidents.
A Rose Cottage spokesperson said the service users died while in hospital and “did not reflect neglect on the part of the household”.
The care service is now under new management, a spokesman confirmed.
Following his inspection on two dates in October 2022, the CQC said: “People were not always safe.
“Medications were not always administered safely.
“Risks to people were not always managed and some care plans did not reflect people’s current needs. Infection prevention and control was not properly adhered to or managed due to lack of cleanliness throughout the day. The staff had been safely recruited, but there were not always enough staff to keep people safe.
“People’s nutritional and hydration needs were not always met and were not effectively monitored.
“Food portion sizes were small, and people were not given any choice about what meals were available to them.
“Staff told us that the house regularly ran out of essentials. People were not supported to have maximum choice and control of their lives and were not supported by staff in the least restrictive way possible.
“We found no evidence of best interest decisions or consents obtained for sensor mats that were in place for multiple people, despite the fact that this is a restrictive practice.
“The service was not always well run. Governance systems to monitor quality and safety were not effective. Audits were completed and sometimes deficiencies found in the inspection were identified, but no action was taken to correct the problems.”
He added: “We will continue to monitor the information we receive about the service, which will help inform the next time we inspect.”
In a statement, the Rose Cottage spokesperson said: “Rose Cottage has always maintained an excellent reputation for the care it provides to professionals and families alike.
“It has been running for over 30 years.
“Unfortunately, at the time of the inspection, the house was under new management and there was a failure to comply with paperwork, including risk assessments and audits. It’s a shame, as users of our service have the security team in place, but the paperwork should fully reflect that.
“The manager has been replaced and the house is back to operating at its high level.
“On inspection, it was evident that the medication was administered safely and PRN protocols implemented; however, the charts were not consistently completed in accordance with the manufacturer’s instructions.
“The public should remember that the inspection is a ‘snapshot’ in time and at the time of the inspection both the home and regular chefs were on annual leave so record keeping and provision of meals were not required. the rule.
“There are now two domestic staff and another chef has been brought in to ensure constant coverage for seven days to ensure this doesn’t happen again.
“In relation to the two deaths, it was the home that sent both service users to hospital, which is where they died (not Rose Cottage).
“One service user was unwell with covid for 13 days (second positive test in a matter of months) and then died in hospital.
“The other, a fall witnessed by staff who ensured that medical attention was received when the service user felt unwell.
“Unfortunately the complications resulted in the hospital and the home documentation was not sufficient. Any complications and CQC are always reported. It did not reflect abandonment by the household.
“Rose Cottage continues to receive support from its staff, service users, families, social workers, professionals and the community at large.
“Inspections have moved further and further away from the ‘care’ focus and years of exceptional care given to paper recording and documentation.
“Rose Cottage has never used agency staff, it provides consistent staff in the most caring and loving home environment so it is disappointing to receive an Upgrade Required.”
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