Roseacre

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to safe care and treatment, premises, recruitment and governance.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Untoward incidents were not always recorded to enable managers to have a meaningful overview of incidents. For example, daily notes indicated one person had acted inappropriately in a shared lounge and in the presence of other people. The records showed this had caused distress to one person. This had not been recorded as an incident. This meant opportunities to learn from incidents might be missed.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Care plans were out of date, and we could not be assured they were an accurate reflection of people’s needs. This is particularly important if people are admitted to hospital in an emergency. An external professional told us equipment to help prevent skin damage had been used incorrectly putting people at risk of harm.

The manager was developing hospital passports to help ensure hospital staff had access to essential up-to-date information. Care plans were being reviewed and updated.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Incident reports showed people had been involved in altercations. These events had not been reported to the local safeguarding team or CQC. An allegation of abuse had been made by a person to two members of staff. The provider told us they had spoken with the person who had withdrawn the allegation. However, there were no records to document the discussion.
Other safeguarding concerns had been reported to external agencies as required.
People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. One person had a DoLS authorisation with conditions attached. The conditions required staff to keep a record of all activities the person was offered and to ensure they were offered access to the garden at least twice a week. There were no records to evidence the person was being asked if they wanted to go into the garden. There was limited recording to show they had been asked if they wanted to take part in any activities. The provider told us the person was fearful of going in the garden. However, this had not been recorded in their care records. Following the inspection the manager told us they had developed a new form for staff to use to record any activities the person was offered. This would be easily accessible for staff to encourage more accurate and timely recording.
Relatives did not have any concerns about people’s safety. Comments included; “[Pronoun] is very safe. The staff are acutely aware of what they are dealing with”, “[Relative] is safer in there than at home” and “From what we have seen we are happy [pronoun] is safe.” People told us they could raise concerns, one person commented, “I have never raised a concern, if I asked for help it would always be given.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments had not been updated to ensure they were still relevant and provided staff with the guidance they needed to support people safely. Some identified risks had not been assessed. For example, one person sometimes became distressed, at these times they could use language which other people found upsetting and intimidating. There was no risk assessment or guidance for staff on how to support the person during these times.
One person had fallen several times between September and November 2025. There was a falls risk assessment in the person’s care plan but this had not been updated since April 2025. However, a manager was able to tell us when the person was more likely to fall and told us the person would require more support at certain times of the day. We observed them supporting the person to walk from the dining room to their bedroom. They were patient and offered support while enabling the person to maintain a level of independence which was clearly important to them.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Outside areas were untidy, at the front of the service there was a large pile of discarded furniture. The back garden was overgrown, and garden furniture was tipped over. One person had a condition on their Deprivation of Liberty Safeguards authorisation which required staff to support the person to regularly use the garden. However, it was potentially unsafe and was not a pleasant environment to use. Following the inspection the provider told us they had tidied garden furniture in the back garden and would be making arrangements to dispose of the discarded furniture.

There were areas of damp and water damage in people’s bedrooms. Dampness can increase the risk of health problems. Environmental risk assessments had not highlighted these areas for improvement.

One person’s bed was positioned so their head was next to a wall socket which was in use. This presented a potential ligature risk. We highlighted this to the manager who told us they would reorganise the room.

Relatives commented; “It doesn’t look the best” and “It could do with some TLC.”

The provider did not have effective processes to ensure necessary safety checks were completed when required. A gas certificate had expired just before the inspection visit and the electrical appliance certificate was due to expire the day following our first visit. Following feedback, a manager took immediate action to ensure these were updated. Other certificates were in date. For example, there was certification to evidence the water system had been checked for legionella. The fire service had completed an audit earlier in the year and there had been no concerns.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

Safe recruitment processes were not consistently followed in line with the service’s policy. Not everyone had 2 references on file. One person had not had a reference returned until after they started working.

The application form did not require candidates to provide dates for any previous employment. This meant the provider was unable to establish if there had been any gaps in employment. Employers are required to record written explanations of any such gaps. There were no interview notes kept, so we were unable to see if employment dates had been looked at during the interview process, or if the questions asked explored candidate’s previous experience and knowledge. This can help employers make decisions about candidates’ suitability for the role. Following feedback, the manager created a pro forma interview template to use in the future which included appropriate questions.

There were enough staff to support people and meet their needs. The rotas showed there was not always on-site management cover at weekends. However, there was an on-call system so staff could ring a manager for advice or additional support if needed.

Relatives did not have any concerns about staffing levels. Comments included; “There seem to be more [staff] recently.... There is always someone around to enter the door code when I leave” and “There is always someone around and if residents are walking around there is always staff talking to them.”
Staff were not receiving regular supervisions or appraisals. The manager told us they were planning to start supervisions soon.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

A shared toilet on the top floor did not have a bin for discarding paper towels after use. On the second and third days of the inspection, cleaning schedules in the shared toilets were for the previous week. We highlighted this to a manager who replaced the cleaning schedules.

There was an infection control policy and a named infection control lead. The policy contained guidance on the actions to take in the event of any outbreaks.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Improvements were needed to the way medicines were managed in the home. There were gaps in people’s medicines records where it was not recorded whether medicines were given or doses omitted. When variable doses of medicines were prescribed how much had been given, was not always recorded. When external preparations were used, which product had been applied was not always recorded. This meant it was not possible to tell whether medicines were given in the way prescribed for people.
Improvements were needed to the way people’s medicines charts were created and checked for accuracy each month. We were told these would be produced by a new pharmacy supplier going forwards.
If medicines were prescribed to be taken ‘when required’ there were protocols to guide staff when these might be needed, but they were not present for all medicines prescribed this way. However, staff were knowledgeable about people’s medicines needs.
We saw medicines administered in a safe way at lunchtime. When medicines were applied in the form of patches, suitable records were kept.
Risk assessments were completed for paraffin-containing emollients, however people’s care plans lacked details for some other medicines. When medicines were given covertly, mental capacity assessments and best interest decisions were carried out, however there was no recorded guidance on how to safely administer each medicine to be given this way. We were told this had been updated following our site visit.
Medicines were stored securely. Temperature monitoring was carried out, however the fridge temperature maximum and minimum range was not recorded to show that these medicines were always stored correctly, as detailed in the home’s medicines policy. Improvements were needed to some aspects of controlled drugs recording.
Staff told us they had in-house training and competency checks to make sure they gave medicines safely. We were told the new pharmacy supplier had visited to train staff following our site visit. There was a medicines policy, however staff were not always following it. Some medicines checks and audits had taken place, and these had identified some issues for improvement. However, some of the areas we found for improvement had not been identified in these audits.