Rosekeys

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed all 8 quality statements in the safe key question and found areas of good practice and of concern. Though the assessment of these areas indicated areas of concern since the last inspection, our rating for the key question has changed to Requires Improvement. Safety risks to people were not always managed well. Managers had not assessed and reviewed safety risks to people and made sure people, and those important to them, were involved in making decisions about how they wished to be supported to stay safe. People and those important to them felt they were safeguarded from harm. Staff understood their duty to protect people from abuse and knew how and when to report any concerns they had to managers. Previously concerns had not always been reported but we noted this had improved using a digital system to better monitor any incidents that occurred. There were enough staff to support people with their needs. Managers reviewed staffing levels regularly to make sure there were always enough suitably skilled and experienced staff on duty. Staff received relevant training to meet the range of people’s needs at the service. Staff received support through supervision and appraisal to support their continuous learning and improve their working practice. Managers made sure recruitment checks were undertaken on all staff to ensure only those individuals that were deemed suitable and fit, would be employed to support people at the service.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives felt that previously people’s quality of life and outcomes had not always been positive and ways of working at the home had not always contributed to safe practice. However, relatives told us that with the new management team in place they could already see some improvements. One relative told us, “Last year we had major concerns, and we raised the concerns with staff at the time but it went nowhere. [Manager] has been explaining what procedures will be put in place regarding staff accountability now and making things right.”

Feedback from staff was mixed regarding learning culture. Most staff told us there was a culture of openness and honesty regarding reporting incidents and concerns. However other staff felt that colleagues were not always honest when incidents occurred, and things were not always reported appropriately. This inconsistent approach meant it was not possible to take a consistent approach to learning lessons when things went wrong and improving practice.

On the previous inspection we highlighted concerns regarding the management of incidents and poor management oversight. During this visit we saw evidence that recent safety incidents were being recorded as they happened, and the manager had oversight, reviewed incidents and monitored them for trends and themes. There was a clear policy on the duty of candour. This policy guided staff to tell the person (or, where appropriate their advocate) when something has gone wrong.

People told us about prior concerns they had regarding the management of safety incidents at the home. However, people did not raise any concerns regarding how safety was currently being managed, monitored or assured. One relative told us, “I have had my concerns in the past but I am satisfied that improvements are being made and that [Relative] is now safe and content at Rosekeys.

The manager told us how they would support safe transition to ensure continuity of care for people. “We would support through the assessment and everything (care planning docs) would go with the person. We would encourage people to come to site to visit, share information on needs, triggers anything to do with individual is transferred over.”

Professionals working with the provider did not feel that they worked with them and supported safe systems of care. Professionals indicated they had concerns with reporting of safeguarding issues and communication regarding people's health and wellbeing.

We were not able to review any documents relating to recent transition between services. The manager told us how they would support a safe transition, “If a person transfers to another service we would support through pre assessment and everything (care planning docs) would go with the person. Engaging with others, share information on needs.” People’s care files contained documentation on their holistic needs. If the person required a hospital admission, this document could go with them to the hospital. However, this information had not been reviewed and was not up to date. This meant hospital staff would not have clear guidance on how the person liked to be supported. Where people required external health and social care support, recent documentation showed that suitable referrals had been made. For example, to the Community Learning Disability Team.

People and their relatives felt people were safeguarded from harm. One person told us how they had been involved in making a safeguarding referral about them with the manager. A relative told us, “Previously injuries were not notified to Local Authority. It’s being done now. I do feel [Relative] is safe here.”

Staff told us they had received safeguarding training, were able to report any concerns and had access to the providers safeguarding policy and procedure. One staff member spoke with us about how they kept people safe from harm and neglect, “By preventing any form of harm, protecting them, continued monitoring and reporting any incidents to my line manager, I ensure people’s safety.” Staff and the management team understood how to respond to allegations of abuse. Staff told us that they had no concerns, but if they did, they were confident the management team would act appropriately. Staff said they felt confident in using whistleblowing processes and if they felt concerns were not being responded to.

During the assessment we did not observe any concerns regarding people’s safety. However, some concerns identified regarding the contents of care plans, adherence to Deprivation of Liberty Safeguards (DoLS) conditions and the environment presented a risk of harm which could have resulted in a safeguarding concern. We saw no evidence that people were at risk or fearful of the staff team.

If an allegation of abuse was made, there were appropriate policies in place to guide the staff team. People were kept safe when they went into the community. For example, where people may be at risk from harm or pose a risk to others appropriate levels of staffing were made available to support them when they went out.

People’s documented involvement in managing risks was inconsistent. One person told us about appointments they had attended to support them to manage stress related behaviours better and how the staff supported them with this. They said, “It makes me feel much better.”

We spoke with the manager about how people were being involved in managing risks as part of service improvements. They told us, "It's not just about risk assessment but talking things through with people including the care plan process. Review risk assessments and make sure it’s fitting to the individual including taking positive risks, giving people the opportunity to do things."

Some people were involved in risk management. We observed people who had previously been unable to independently make a hot drink being supported by staff to do this. We saw information recorded where people had actively been engaged with recording an incident relating to risk to themselves. These activities had very recently been implemented to involve people more effectively in risk management relating to their care and support.

People’s needs were not clearly documented in their care plans, so staff lacked clear guidance on a person’s mental, physical, communication and social needs. However, staff did appear to know how to support people to manage risk. For example we saw one person supported by staff to de-escalate when they were getting agitated and supported them to become more relaxed. Staff had received training on how to support people’s individual needs. Some people at the service could become distressed due to their health diagnosis. Staff had received training on how to support people when they became agitated.

People and relatives did not communicate any specific safety concerns around the environment other than the cleanliness.

Staff told us they felt the environment was safe and were able to tell the inspection team what things were in place to maintain a safe environment. One staff member told us, “The home is equipped with safety features like grab bars, non-slip mats, and emergency alert systems. Regular safety drills and maintenance checks are conducted to ensure all equipment is functional. Additionally, there are clear policies and procedures for handling emergencies, ensuring both staff and residents remain safe and well-supported in all situations.”

We found the environment was not always safe. We observed 2 wardrobes which were not secured to the wall which posed a risk of falling and injuring someone. The home was not safe in the event of a fire and we observed a fire door which led to someone’s bedroom that did not close completely. There were areas of the building where there was broken furniture in communal spaces and soiled mattresses in people’s bedrooms. Windows were unable to be opened wide. This safety feature prevents people from falling or climbing out and is in line with guidance from the health and social care executive.

The environment was not always kept safe. The provider had processes in place to maintain a safe environment however these processes had not effectively identified concerns found by the inspection team. We saw that management walk arounds had failed to identify an issue with a fire door and other environmental risk factors. Some processes were completed by external contractors including checking the water temperatures and legionella checks. Internal processes require to be improved and carried out consistently to ensure people’s home environment remains safe.

People felt that staffing issues had improved with the new management team and noted previously they had concerns with staff turnover and poor communication. One relative told us, “There was no engagement or interaction with staff. Staff turnover was horrendous. [Manager] has been explaining what procedures will be put in place re accountability and making things right.”

Staff told us they felt they had received appropriate training to support them to safely carry out their role. However, not all staff felt there were always enough staff available and that additional staff at key points of the day would support to ensure people received the care and support they needed.

We saw there were enough staff to provide support to people safely. Staff were deployed effectively around the building, to provide timely support to people. We observed that people who required 1:1 support to ensure they were safe was in place and the manager considered staffing levels both at the home and out when people had outings and required additional staff to safely support this.

The provider used a tool to determine how many staff people required and were required at the home to ensure their safety. This tool identified when people required 2:1 support, for example: for an outing. The provider tracked staff training on their training matrix. Some staff required specific training which had not been completed but we saw that this had been scheduled and staff booked on. The provider had safe systems in place for recruitment of staff.For example, previous employers were contacted to give references on the staff member. Staff had also had regular Disclosure and Barring Service (DBS) checks. These check the police database for convictions or warnings that may impact the staff members safety to work with people.

People didn’t raise any concerns about the current cleanliness of the environment but did point out that they had concerns prior to a recent change in the management and staff teams. One relative told us, “It’s a remarkable change from last time we came to where they are now, decoration cleanliness and actual overall smell there’s a huge difference.”

Staff knew what personal protective equipment they should wear and when to wear it. This protected people from the spread of infection. Staff told us they felt the home was clean and they had access to personal protective equipment (PPE). Staff understood the importance of supporting people to maintain good hygiene as part of infection prevention and control. One staff member told us, “I support and encourage people with hand washing, their personal hygiene routine with personal care products and by creating supportive environment”.

The home was not clean and hygienic in all areas and there was evidence where we found the home required deep cleaning. We saw examples of dust, dirt and cobwebs on surfaces and a person’s bath was seen to be soiled, however we recognise that the person was in the middle of their morning routine and their care was priority. Faeces was found on a person’s toilet seat, and a soiled mattress was being stored in a person’s rooms. We saw that staff had access to personal protective equipment (like gloves) throughout the home. This allowed them to support people in a hygienic way.

The provider had a current infection prevention and control policy, had employed a full time cleaner, and the management team had recently implemented a daily management walkaround procedure to identify issues around the home. Newly implemented processes were not fully embedded but at the time of assessment had failed to identify areas that required attention relating to infection prevention and control. This meant people were not always protected from the risk of infection.

People and relatives did not report any concerns regarding how people were supported with medicines. One person's relative told us, "I have no concerns or worries about the administration of [relative] medication.”

Feedback from staff was mixed, some staff felt medicines were consistently managed safely and some staff said there were occasional concerns about missed medicines. One staff member told us, "We have access to medicines care plans and PRN (as needed) protocols which helps manage medication effectively, ensuring safe and appropriate administration".

The provider had a current medicines policy and protocol for the use of as required medicines. Medicines were stored in a locked area, to prevent people accessing them unsafely. Medicines records were completed consistently and where people didn’t want to take a medicine or it wasn’t given for any other reason this was recorded as well as any follow up action and outcome. Staff kept clear records of when they had given prescribed medicines. We saw medicines were given as prescribed. Staff had received training on how to administer medicines safely.