The Care Quality Commission (CQC) has rated Rosekeys care home in Gringley-on-the-Hill inadequate and placed it into special measures to protect people, following an inspection in November.
Rosekeys care home, run by Lifeways Rose Care and Support Limited, is a residential care home providing accommodation and personal care to people with learning disabilities and autism. The service can support up to 13 people. There were nine people using the service at the time of the inspection.
This inspection was prompted due to concerns CQC received in relation to incident reporting, safeguarding, management and staffing.
Following this inspection, the service’s overall rating has dropped from good to inadequate, as has the rating for being safe and effective. The well-led rating has dropped from requires improvement to inadequate. As this was a focused inspection, caring and responsive were not included and remain rated good from their previous inspection.
The service is now in special measures, which means it will be kept under close review by CQC to keep people safe and it will be monitored to check sufficient improvements have been made.
Greg Rielly, CQC deputy director of operations in the midlands, said:
“When we inspected Rosekeys care home, we were disappointed to see leaders didn’t understand the issues they faced resulting in a poor level of care being given to people in the service. This is because they didn’t understand the issues so couldn’t address concerns or put systems and processes in place to make things better.
“During our visit, we found people weren’t always safe from the risk of abuse. One person using the service reported that a member of staff threatened to remove their social opportunities if they didn’t behave well. There was another incident where someone was physically restrained but staff failed to follow the person's care plan, putting them at risk of harm. At the time, our inspectors were so concerned they spoke to the provider and the local safeguarding authority for investigation.
“Further incidents had also not been reported, for example, a person had sustained multiple head injuries following falls, some of these unwitnessed. The provider hadn’t reported these incidents which put people at continued risk of injuries from falls.
“On one occasion staff didn’t follow medical advice to take someone to hospital for checks. This led to their condition getting worse, and them having to make a potentially unavoidable trip to hospital. In another example, staff didn’t help a person access medical advice for their health condition, even though monitoring showed they needed it. This left people at risk of serious harm.
“Furthermore, there were serious environmental risks at the home. We saw electric heaters weren’t always at a safe temperature and a boiler room with exposed pipework was left unlocked putting people at risk of burns. We also saw a wardrobe wasn’t attached to a wall and could have been dangerous if it fell on people. Following our inspection team raising these concerns, the service rectified the issues.
“We have told Rosekeys care home where we expect to see rapid and widespread improvements and will continue to monitor them closely to keep people safe while this happens. We will return to check on their progress and won’t hesitate to take action if people are not receiving the care they have a right to expect.”
Inspectors found:
- Staffing arrangements were not always effectively managed to ensure people's needs were met
- Staff did not always have the right training and knowledge to support people effectively
- Processes failed to identify risk and improve the quality of the service
- Staff and members of the management team did not understand how to mitigate risks and protect people from the risk of abuse
- Care plans and risk assessments failed to consistently outline people's needs and staff did not always understand the level of care people needed
- The values, attitudes and behaviours of leaders and care staff did not ensure people using services led confident, inclusive and empowered lives
- The manager was not always available for relatives and some staff told us were not always confident in the manager's approach.
The report will be published on CQC’s website in the next few days.