CQC - Care Quality Commission

11/19/2021 | Press release | Distributed by Public on 11/20/2021 03:27

CQC rates Roop Cottage Nursing and Residential Home in Pontefract inadequate and places it in special measures

The Care Quality Commission (CQC) has taken action against a Pontefract nursing and residential home following an inspection in August which led to it being rated inadequate and placed into special measures.

The inspection was carried out due to concerns received about infection prevention and control as well as staffing levels.

Following the inspection, CQC rated the service inadequate overall and inadequate for how safe and well-led the service is. It is rated requires improvement for being effective, caring and responsive.

CQC also placed the service in special measures, which means that it will be closely monitored to ensure that people are safe. If fundamental improvements have not been made by the time of the next inspection, CQC will take further enforcement action to ensure people are not exposed to a service which does not meet standards they have a right to expect.

Roop Cottage is a care home providing residential and nursing care to up to 35 people. At the time of the inspection, there were 26 people living in the home.

Sheila Grant, CQC's head of adult social care inspection, said:

"When we inspected Roop Cottage Nursing and Residential Home, we found a disorganised service, where a lack of strong leadership was impacting on every aspect of people's care.

"This was not a safe place for people to call home. Vulnerable people who rely on staff taking steps to protect them were unable to do so. Inspectors found serious safeguarding concerns, particularly where two people identified as a risk to each other's safety, spent long periods of time together, and an unlocked, unsupervised kitchen area where pans were boiling, and a knife could be accessed.

"Leaders did not learn from previous incidents to protect people. Someone managed to leave via the kitchen, and no action had been taken to reduce the risk of this happening again.

"With regards to COVID-19, there were no systems in place to check if visitors were safe to enter the home. People and staff were not having regular testing, and staff were seen not wearing PPE appropriately or not wearing it at all.

"There was a lack of personalised care. People didn't receive their meals when they wanted, we saw some people waiting two hours for their breakfast. The provider must ensure they take people's personal needs into account when it comes to meal times.

"Staff didn't feel supported and there was a lack of communication from the management team.

"Since our inspection, some improvements have been made around COVID-19 as well as other concerns highlighted. We will continue to monitor the service closely and will take further action if we are not assured it is making necessary improvements."

Inspectors found:

  • Medicines were poorly managed, and systems were disorganised. Medicines were not stored safely and there was an absence of some records needed to ensure this process was safe.
  • A faulty fire door leading to a flight of stairs had not been identified as a risk.
  • Staff knowledge around the number of people living in the home and who had a choking risk varied. Knowledge around how to meet people's dietary needs was not evident.
  • The provider did not have an overview of which people were under a do not attempt resuscitation order.
  • Some concerns have been identified around maintaining people's privacy and dignity.


  • People we spoke with said the staff were caring and tried their best to take care of them.
  • People engaged well with the activities programme which was run by a coordinator who shared a genuine interest in making this enjoyable for people.

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