Rodwell House received an overall 'Requires Improvement' rating with 'Good' for safe and caring, but persistent shortfalls in activities provision, staff understanding of the Mental Capacity Act, and inconsistent adherence to individual care preferences across effective, responsive, and well-led domains. The service had made notable progress since the previous inspection — including safe medicines management, dementia-environment adaptations, and strengthened leadership — with no regulatory breaches identified at this visit.
Concerns (5)
moderateConsent / capacity: “Some staff we spoke to told us they did not fully understand the Mental Capacity Act, even though they had training in this area.”
moderatePerson-centred care: “one person who had requested only female staff, had care given by male staff on occasions. Another person's plan said they liked to shower twice a week, but this was not happening.”
moderateGovernance: “the provider had systems in place to regularly review the care plans and although these were up to date, the provider had not identified these issues.”
moderateOther: “The service had recruited one activity coordinator, but more were required...Most people told us there was not enough for them to do and they mainly spent time in their rooms watching television.”
minorInfection control: “Sluice rooms (dirty utility rooms) were not being used correctly. We fed this back to the provider and recommended they seek further guidance in this area.”
Strengths
· Medicines managed safely with regular audits, competency assessments, and documented lessons-learned processes following errors
· Risk assessments were clear, comprehensive, and up to date using recognised tools; monitoring charts and pressure mattress settings checked regularly
· Staff consistently described as kind, caring, and treating people with dignity and respect by people, relatives, and through direct observation
· New registered manager found supportive and approachable with an open-door policy; positively received by staff, people, and relatives
· Practice development team introduced to work alongside care workers and embed best practice through live coaching and competency assessments
Quality-Statement breakdown (25)
safe: Assessing risk, safety monitoring and managementNot rated
safe: Preventing and controlling infectionNot rated
safe: Staffing and recruitmentNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Learning lessons when things go wrongNot rated
safe: Using medicines safelyNot rated
effective: Adapting service, design, decoration to meet people's needsNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Assessing people's needs and choices, delivering care in line with standards, guidance and the lawNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Staff working with other agencies to provide consistent, effective, timely careNot rated
caring: Ensuring people are well treated and supported, respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Supporting people to develop and maintain relationships to avoid social isolation; support to follow interests and activitiesNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: How the provider understands and acts on the duty of candourNot rated
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsNot rated
well-led: Continuous learning and improving careNot rated
Rodwell House improved from Inadequate to Requires Improvement across all five key questions, exiting some prior breaches but remaining in breach of Regulations 12 (safe care) and 17 (good governance) due to unembedded risk management, deployment issues and a management-driven cultural divide. Improvements were noted in safeguarding, infection control, medicines, MCA compliance and the ground-floor environment, but further work is required on risks, activities for room-bound residents, and leadership culture.
Concerns (10)
criticalGovernance: “the lack effective governance arrangements meant there was a continued breach of Regulation 17”
criticalLeadership: “management had created a cultural divide within the service, the provider remained in breach of Regulation 17.”
criticalCare planning: “their risk assessment had not been reviewed for over a month and staff had not been monitoring this person's weight more frequently.”
criticalSafeguarding: “One person was without their call bell. They told us, 'They took it away as I was a nuisance. I can wait ages. I have to scream to be heard.'”
moderateStaffing levels: “There is a shortage of staff and my concern is the time it takes for staff to get to her when she rings the bell.”
moderateCommunication with families: “It's a disappointment because she doesn't communicate with us. There are no residents/relative meetings.”
moderateCultural competency: “There is a language barrier. I can't understand a word they are saying, it makes me feel anxious. They stand over you and talk in their own language every day.”
moderatePerson-centred care: “people who were cared for in their bed, or who spent all of their time in their room, were at risk of social isolation as staff were too rushed to spend meaningful time with them.”
moderateOther: “we again found this cupboard unlocked. We reported this to the registered manager.”
minorRecord keeping: “we found a lack of personal history in people's care plans. A staff member said, 'I don't know anything about his background, but it would be useful to know.'”
Strengths
· Improvements in safeguarding recognition, reporting and investigations; no longer in breach of Regulation 13
· Infection prevention and control measures were assured across all areas inspected
· Medicines were administered, stored and recorded safely with good clinical knowledge from staff
· MCA assessments and DoLS authorisations now in place; no longer in breach of Regulation 11
· Improved staff training (99% compliance) and supervision; no longer in breach of Regulation 18 for competency
Quality-Statement breakdown (20)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongGood
safe: Preventing and controlling infectionGood
safe: Using medicines safelyGood
effective: Assessing people's needs and choices; delivering care in line with standardsRequires improvement
effective: Staff support: induction, training, skills and experienceGood
effective: Ensuring consent to care and treatment in line with law and guidance
Rodwell House deteriorated to Inadequate and was placed in special measures, with continued and new breaches of Regulations 9, 10, 12, 13, 17 and 18 covering staffing, infection control, safeguarding, dignity, person-centred care and governance. Despite some kind individual staff and safe medicines practices, persistent management instability (13 managers in six years), insufficient staffing and a failure to learn from previous inspections left people at risk of avoidable harm.
Concerns (14)
criticalStaffing levels: “The failure to provide a sufficient number of suitably qualified, competent and skilled staff in order to meet people's needs was a breach of Regulation 18”
criticalInfection control: “Sluice rooms on two floors were not being used correctly by staff and two smelled strongly of urine... There was also faecal staining on some of the equipment.”
criticalSafeguarding: “The lack of robust processes in place to help ensure people are safeguarded from abuse and improper treatment was a breach of Regulation 13”
criticalGovernance: “The on-going lack of good governance and management oversight or commitment to improve people's care was a continued breach of Regulation 17”
criticalLeadership: “In the last six years, this service has had 13 managers. All of whom had left after a short period of time and only two of those had registered with CQC.”
criticalStaff competency: “The failure to ensure staff are sufficiently competent to provide care in a safe way was a breach of Regulation 18”
criticalPerson-centred care: “The registered provider was not providing person-centred, responsive care to people in order to meet people's individual characteristics and to avoid social isolation.”
criticalIncident learning: “lessons had not been learnt as changes had not been made to the service to help ensure people were free from potential abuse.”
moderateStaff training: “where shortfalls or concerns had previously been identified at this service, training had not taken place with staff to help ensure they did not reoccur.”
moderateCare planning: “People's care plans were not contemporaneous, and staff were not always able to tell us about people's individual care needs.”
moderateConsent / capacity: “One person was determined as lacking capacity to make complex decisions, but there was no best interests paperwork to support any decision made on their behalf.”
moderateCommunication with families: “There is constant management change which is really quite worrying. We never receive any correspondence and there aren't any meetings.”
moderateCultural competency: “people reported staff continued to speak in their own language, rather than English. This was identified at previous inspections.”
minorComplaints handling: “complaints... were not stored as a separate log and as such it was difficult to see what action had been taken, whether the complaint was resolved”
Strengths
· People received the medicines they required and staff followed good medicine administration practices
· Electronic medicine administration system with alerts for missed or late medicines
· Robust recruitment processes including DBS checks
· Staff completed an induction period including the Care Certificate before working unsupervised
· Referrals to healthcare professionals (SALT, GP, physiotherapist, dieticians) evidenced in care plans
Quality-Statement breakdown (17)
safe: Staffing and recruitmentNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Preventing and controlling infectionNot rated
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongNot rated
safe: Using medicines safelyNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law
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Good
effective: Staff working with other agencies to provide consistent, effective, timely careGood
caring: Ensuring people are well treated and supported; respecting equality and diversityRequires improvement
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationRequires improvement
responsive: Planning personalised care to ensure people have choice and controlGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Duty of candour; engaging and involving people, public and staffRequires improvement
well-led: Continuous learning and improving care; Working in partnership with othersGood
Not rated
effective: Supporting people to live healthier lives, access healthcare services and supportNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Supporting people to develop and maintain relationships to avoid social isolationNot rated
responsive: End of life care and supportNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: Meeting people's communication needsNot rated
well-led: Promoting a positive culture; Engaging and involving people; Continuous learning and improving careNot rated
well-led: Duty of candour and working in partnership with othersNot rated