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We are carrying out a review of quality at Roxburgh House. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 17 June 2021

About the service

Roxburgh House is a residential care home providing personal to 14 people with a variety of needs. People’s needs include, physical disabilities, dementia, learning disability or long-term mental health conditions. The service can support up to 22 people in one adapted building.

People’s experience of using this service and what we found

People were not always safe at Roxburgh House. Some people told us they were scared at times. Allegations of abuse and incidents between people had not been shared with the local authority safeguarding team so they could be investigated.

There was a continued lack of effective leadership and oversight by the provider and this had led to failures throughout the service. The provider had failed to make the required improvements following the last inspection in September 2020 and breaches of regulation continued. Checks and audits completed had not identified the shortfalls we found at the service. People were not valued and were not at the centre day to day life at the service. They were not encouraged or supported to maintain and develop their independence. People’s views and opinions were not listened to.

The provider had not developed an open culture and there was a lack of trust and respect between the provider and staff. Most longstanding staff members had left. A blame culture had developed between the provider and staff and staff did not work as a team to support people.

Risks associated with diabetes, epilepsy, choking, catheter care and behaviours which challenge had not been robustly assessed and action had not been taken to reduce risks to keep people safe. People continued not to be protected from the risks in the event of a fire. Accidents and incidents were not reviewed to identify any patterns or trends and reduce the risk of them reoccurring.

Medicines were not managed safely. People did not always receive the medicines they were prescribed by their doctor and one prescribed medicine was shared between four people. There continued to be no guidance available for staff about people’s ‘when required’ medicines.

Improvements made to staff recruitment process had not been maintained. People were not protected from the risks of staff who did not have the skills to fulfil their role or were not of good character. Staffing levels were not consistent to ensure people received the care and support they needed. Staff continued to work long hours.

The cleanliness of the building had improved but people continued to be at risk from the spread of infection. Laundry and rubbish were not managed or stored safely. Government COVID-19 guidance had not always been followed. The new manager had not begun to develop their relationship with other professionals involved with the service

Records at the service were inaccurate or incomplete. Medicines records contained gaps in the administration of medicines and some important records could not be found such as medicines sent for destruction. Staff rotas did not reflect who had worked at the service. Some recruitment records were not easily accessible. Personal information about people was not held securely.

For more details, please see the full report which is on the CQC website at

Rating at last inspection (and update)

The last rating for this service was inadequate (published 14 November 2020) and there were multiple breaches of regulation. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about the leadership and culture of the service, maintenance of the building, the registered manager leaving and staff not being able to meet people’s needs. A decision was made for us to inspect and examine those risks and follow up on action we told the provider to take at the last inspection. We undertook a focused inspection to review the key questions of safe and well-le

Inspection areas



Updated 17 June 2021

The service was not safe.

Details are in our safe findings below.


Requires improvement

Updated 17 June 2021



Updated 17 June 2021


Requires improvement

Updated 17 June 2021



Updated 17 June 2021

The service was not well-led.

Details are in our well-Led findings below.