CQC report explained · a residential care home
What the CQC found at Rosekeys
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, February 2024
Rated Inadequate and placed in special measures; inspectors found serious risks involving safety, care, staffing and management.
Inspectors visited without notice on 28 November, 29 November and 11 December 2023. They spoke with people, relatives, staff and professionals. They observed care and checked care plans, medicines records, recruitment files and management audits.
They found people were at risk of avoidable harm. Medical advice was not always followed, medicines were not always given as prescribed, staffing did not always meet people's assessed needs, and some staff lacked the training and practical skills required.
Inspectors also found unlawful restrictions, poor safeguarding responses, incomplete care plans, a poorly maintained and unclean environment, and weak checks by managers and the provider. The overall rating changed from Good at the previous inspection, published in 2021, to Inadequate.
The home is in special measures. CQC will keep it under review and normally re-inspect within six months if it does not propose cancelling the provider's registration.
Some people felt safe
People and most relatives spoken with said they felt the home was safe.
“People and most relatives we spoke with felt the care provided was safe.” from the report
Safe recruitment checks
The report says staff recruitment checks were completed, including Disclosure and Barring Service checks.
“Staff were recruited safely. Staff had relevant Disclosure and Barring Service (DBS) checks in place.” from the report
Personalised rooms
Some bedrooms were personalised, and some areas included decorations or features people could interact with.
“People's rooms were personalised and areas of the service had decorations people could interact with.” from the report
Some positive outcomes
There was evidence that at least one person was supported to complete a qualification that could help with future employment.
“There was some evidence of people achieving positive outcomes.” from the report
People were at risk of harm
seriousMedical advice was not always followed, risks were not properly assessed, and some environmental hazards were not dealt with. Inspectors said this left people at risk of serious or avoidable harm.
“This left people at risk of serious harm.” from the report
Safeguarding failures
seriousSome incidents involving restraint, possible psychological ill treatment and injuries were not reported promptly to the local safeguarding authority. People were therefore not always protected or independently reviewed.
“People were not protected from the risk of abuse. This was a breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Staffing and training
seriousStaffing did not always match people's assessed support needs. Some staff also used unsafe moving and handling techniques or did not have up-to-date training for people's health conditions.
“The provider failed to ensure sufficient numbers of staff were deployed.” from the report
Medicines and health advice
seriousMedicines were not always given as prescribed, and records and storage checks were incomplete. Advice about choking, weight loss and other health needs was not always followed.
“Medicines were not always given as prescribed.” from the report
Poor dignity and privacy
seriousThe environment and some care practices did not protect people's privacy or dignity. Examples included exposed personal items, unsuitable bedroom arrangements and incomplete privacy screening.
“The provider failed to ensure people were treated with dignity and respect.” from the report
Weak management oversight
seriousThe provider's checks did not identify or fix important risks, including problems with incidents, infection control, medicines, care plans and the condition of the building.
“The provider's systems and processes failed to assess, monitor, and improve the quality and safety of the service provided.” from the report
- 01What immediate changes have been made to ensure people's assessed staffing levels, including 2:1 support, are provided on every shift?
- 02How are safeguarding incidents, restraints, falls and possible abuse now recorded and reported to the local authority?
- 03How do you check that medicines, choking guidance, weight checks and other professional advice are followed for each person?
- 04How have care plans and risk assessments been updated, and how do you check that staff understand them?
- 05What action has been taken under the special measures plan, and what evidence can you show of improvement since the inspection?
This was an unannounced focused inspection of Safe and Well-led, widened to include Effective after inspectors found a concern about deprivation of liberty; the report does not give separate current ratings for Caring or Responsive. This explanation was written from the published report of 15 February 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, November 2021
Rosekeys is rated Good overall; inspectors found safe and effective care, but leadership and some improvement work still needed attention.
This was an unannounced focused inspection on 27 October 2021. One inspector spoke with people, staff and visiting professionals, and reviewed care plans, medicine records, staff files and management records.
The home had improved since the previous inspection. Staff training and medicine checks had improved, risks were managed, and people told inspectors they felt safe. Care plans were detailed, and staff worked with health professionals to support people's health.
The overall rating changed from Requires Improvement to Good. Safe and Effective were rated Good. Well-led remained Requires Improvement because improvements were not yet fully sustained under a recently changed management team. Caring and Responsive were not assessed in this focused inspection.
People felt safe
People told inspectors they felt safe. Staff knew how to recognise and report safeguarding concerns, and risks were regularly reviewed.
“People told us that they felt safe with staff.” from the report
Medicines were managed safely
There had been no medicine errors since the previous inspection. Staff competencies were checked and medicine records were monitored.
“Since our last inspection there had been no medication errors.” from the report
Detailed care planning
Care plans were personal to each person and focused on positive outcomes. Staff supported independence, routines and access to the local community.
“People's care plans were person centred and focused on people achieving positive outcomes.” from the report
Improved staff training
The home had addressed earlier training shortfalls. New staff completed induction and shadowed experienced staff before working unsupervised.
“At this inspection we saw evidence to confirm staff had now received the required training” from the report
Occasional staff shortages
needs fixingStaff said that last-minute absences sometimes left the home short staffed. Agency staff were used and recruitment was continuing.
“Staff told us, on occasions due to last minute staff absence, the service ran 'short staffed'.” from the report
Leadership was not yet consistent
needs fixingThe well-led rating remained Requires Improvement. Inspectors found recent management changes and recorded a staff concern about the lack of visible senior leadership, although the provider gave a different response after the inspection.
“Senior management never come over here, there is never any real leadership here. Over the last few years, it's been left to run itself.” from the report
Some areas needed refurbishment
minorSome parts of the home still needed updating and redecorating. Inspectors said the concerns had not always been dealt with promptly.
“Some areas of the home still needed updating and refreshing, and no changes had been made since our last inspection.” from the report
- 01How will you make sure staffing levels are safe when there are last-minute absences?
- 02What is the timetable for refreshing and redecorating the communal areas?
- 03How will the new management team provide visible and consistent leadership at the home?
- 04How are staff training records and refresher training checked now?
- 05How will you show that the improvements from the last inspection are being sustained?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not assessed, and ratings from the previous comprehensive inspection were used where needed. This explanation was written from the published report of 30 November 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Rosekeys
6 rated inspections over 9 years: the service has slipped, from Requires improvement to Inadequate.
- February 2024Inadequatecurrent ratingdown from GoodSafe: InadequateEffective: InadequateCaring: GoodResponsive: GoodWell-led: Inadequate
- November 2021Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Requires improvement
- July 2021Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- October 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- March 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 26 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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