Ensuring ‘Confidence in Care’
through proactive and positive change
Ensuring ‘Confidence in Care’
through proactive and positive change
Thank you for taking an interest in finding out more about all the good work and superb progress that has been underway at Dora Rose since the last CQC inspection, undertaken in Spring 2023.
The following information has been collated to provide transparency and assurance for those considering residential care at Dora Rose for a loved one, to help ensure that such an important choice is fully informed.
About CQC methodology
The CQC is currently undertaking a whole system review of its inspection services, with new methodology yet to be published but expected to come into force in the latter part of 2023.
For the MACC Care Group this means that services are no longer being inspected based on CQC’s frequency model in line with the current gradings.
CQC continues to regularly inspect services whilst it undergoes transformation and its current decision to inspect is based on knowledge of their locations and through that knowledge, perceived ‘risk.’
Date of last CQC published inspection report – 08 March 2023 (This inspection focused on only two key lines of enquiry ‘Safe’ and ‘Well Led’ – there are five in total).
Ratings from a previous inspection for the key lines of enquiry, ‘Effective,’ ‘Caring’ and ‘Responsive’ remain from the last inspection as ‘good’ which was published on 29 June 2021.
Overall rating: Requires Improvement
Key findings indicated that:
- Issues were identified in repositioning times not being recorded in line with information contained within the care plan.
- A sample of plans did not reflect the latest care instructions that staff were following.
- Two staff were unaware of a person’s specific health conditions.
- The home had not implemented the provider’s most recent change in medications records templates.
- Quality Audits sampled did not identify the particular deficits in the sample of care plans the inspectors reviewed.
Highlights from the CQC report
The report also identified many positive examples of best practice:
- Medication quantities matched the stocks in place.
- Staff were observed by the inspector to administer medication in a dignified way.
- The service was working within the principles of the mental capacity act.
- Systems were in place to keep people safe from abuse.
- People and relatives told the inspectors that they or their family member received safe care.
- Staff knew how to recognise and report potential abuse and had received training.
- Staff recruitment practices were safe.
- There were procedures in place to ensure people were protected from potential harm and appropriate referrals made where required.
- Infection prevention control measures were good.
- Lessons were learnt when things went wrong.
- Accidents and incidents were reviewed for patterns, themes and trends.
- Environmental and infection control checks were regularly carried out by the provider and appropriate action taken.
- The service worked closely with other agencies.
- Feedback was sought from people who lived at the home. The information was analysed and shared.
- There was a positive culture which valued and promoted people’s individuality.
- Relatives said the culture was inclusive and empowering.
- Staff felt respected, supported and valued by the senior staff.
- Staff shared how lessons learnt were cascaded with them.
- Resident and relative meetings were embedded and relatives felt engaged with the service.
- Audits systems were in place.
- Staff felt able to suggest improvements to care practices for the benefit of the residents.
- Relatives felt able to contribute to the running of the home.
- The service engaged with health care initiatives and within the local community.
Driving changes for the better
Following the CQC inspection, MACC Care has taken the following steps to improve the service:
- As an organisation we did not agree with the findings from this report and provided a substantial factual accuracy challenge which CQC chose not to largely uphold.
- We submitted an action plan advising CQC that we did not believe that we were in breach of the Regulations and the small deficiencies identified were rectified at the time of the inspection.
- Since this inspection, the new Home Manager has been registered with CQC as a responsible person following their assessment.
- Lessons learnt were written and shared with other Managers within the Group so that insights could be shared. Changes in practice (where identified) were made to further improve and drive quality.
- Since the last CQC inspection, we have undertaken a Survey with key people who work and visit our services and developed a ‘you said, we did’ response to this.
Other key themes from their survey feedback included:
- 88% of relatives rated the home ‘Good’ or ‘Outstanding’ for how they liaised with other health care professionals.
- 89% of relatives rated the home ‘Good’ or ‘Outstanding’ for how they manage feedback.
- 100% of relatives felt the home always followed guidance to keep them and their loved one safe during the pandemic.
- 100% of residents felt safe, free from harassment and abuse.
- 92% of residents felt their feedback would be listened to and changes made quickly.
- 100% of residents rated our staff ‘Good’ or ‘Outstanding’ for the help they provide to them.
- 90% of residents felt involved in their care planning.
- 100% of residents rated staff ‘Good’ or ‘Outstanding’ for helping them to stay as independent and healthy as possible.
- 95% of the staff felt they were encouraged to liaise with other health care providers for the benefit of their residents.
- 99% of staff felt that the environment and equipment was well maintained.
- 93% of staff felt that their Manager provided them with the right information to enable them to deliver care in a safe way.
Internal Review processes
Frequent and thorough appraisal of services for your peace of mind
- Internal support teams at MACC Care are on hand to individually support our homes to deliver the best quality resident experience. Additionally, a range of audits are regularly undertaken at both home and organisational level to offer additional quality assurance.
- Internal home audits are completed in line with MACC Care’s Internal Governance Schedule – any patterns or trends are reviewed and added to the home’s service progression plan. This is regularly reviewed to ensure actions are sustained and embedded before they are authorised as closed.
- Insight Reviews have been developed and rolled out (MACC Care’s internal review methodology mapped to CQC’s methodology and regulations) and these are undertaken every six months.
- Follow-up Reviews are undertaken in between Insight Reviews to ensure that any areas for focus are addressed and the change in practice embedded.
- Regular Operational Visits are conducted to support the home manager in service development and a reporting structure is in place to provide organisational assurance.
- Regular visits are also conducted by the Director of Regulation and Director of Operations
- Regular ‘Meet the Manager’ events are held for families and friends of Dora Rose.
Dora Rose is currently rated 9.6/10 by significant others
We welcome feedback from our residents and relatives. To view the most recent comments, please the Meadow Rose page at carehome.co.uk
“I am inspired everyday by my fantastic staff team who will always go the extra mile to make our residents and relatives feel confident and safe in our care. Dora Rose is a really beautiful home set in stunning grounds in a lovely part of the world; with a great staff group who really do care about what they do.”
Emma Thorley, Dora Rose Manager
To find out more about the great things that are happening at Dora Rose and the compassionate care and support available to your loved one, please email Emma or call her on 01785 594991.
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