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

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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

We saw that accidents and incidents were consistently recorded and reviewed to identify any themes and trends. The registered manager showed us a group communication channel used with the staff team which evidenced learning from when things didn’t go well and advised staff of the correct action to take to avoid recurrence.

We considered the risk of closed cultures during the assessment but did not identify any concerns relating to this. Any service that delivers care can have a closed culture. We define this as ‘a poor culture that can lead to harm, including human rights breaches such as abuse’. In these services, people are more likely to be at risk of deliberate or unintentional harm.

This meant people received care and support that was safe, and improvements were made when concerns were identified.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

We saw examples of communication and appointments with external professionals. We reviewed an example of an incident that had resulted in a person being taken to hospital and how continuity of care was supported by a staff member, familiar to the person, going with them in the ambulance after additional support was secured using the homes on call system.

We spoke with the covering registered manager about referrals into the home and how they ensured people were the right fit for the service to ensure it met their needs and didn’t impact the care other people were receiving. They told us, “We have got

the level of need and matching tool. So, we will do that and [also consider] shared interests and hobbies.”

This meant people received the right care and support to meet their individual needs and preferences.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People and relatives felt they were safeguarded from avoidable harm. We asked one relative if they had any concerns about their loved one’s safety. They said, “No definitely not, I don’t have any concerns, they [staff] watch out for them and they [staff] are really good with [relative].”

Where restrictive practice was being used, they were legally justified, proportionate, necessary and as a last resort. We saw that people’s capacity was considered and decisions on safety made in their best interests.

Staff completed safeguarding training, and the provider had a current policy in place to guide staff on how to protect people to live in safety and free from avoidable harm.

The provider did not always work well with people to understand and manage risks. Whilst staff generally provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them, we did note an instance during the assessment where staff did not proactively manage risk relating to a person’s health.

This was highlighted with the management team during the assessment, and the regional manager has since confirmed they had a conversation with the staff to empower them to make better decisions and speak up about concerns regarding risk to people.

We saw examples of people wishing to undertake goals and how staff would support them to achieve these goals whilst mitigating any risks as far as possible. Whilst these examples and risk assessments were not always clearly documented, people and staff were able to tell us about what they were doing to support individuals in a way that was empowering and enabling.

The provider identified and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. However, we noted that documentation and systems were not always implemented in full at the home presenting a risk of avoidable harm to people.

Whilst we saw no evidence of how people had been consulted about the environment to ensure adaptations and reasonable adjustments were made to meet their individual needs, the director explained that as people were referred and moved into the home there would be further discussion around the environment to ensure that it was personalised and met people’s needs.

Whilst we did note that one door to an electrical cabinet was not appropriately secured this presented a very low risk of harm to the people currently living at Rosekeys and was addressed immediately.

There was an emergency red bag to be used in the event of a fire or other emergency evacuation situation. There were 3 copies of the business continuity plan in the bag, but the document was not completed in full, including missing details of next of kin, which could lead to confusion in the event of an emergency. Personal emergency evacuation plans were much clearer with the except for one person’s which had repeated information in and step by step evacuation guidance was missing.

Previously highlighted concerns around the environment had been addressed by the provider and doors to areas that should not be accessed by people supported were secured to reduce the risk of avoidable harm. This meant people were able to live in a safe environment and were proactively protected from harm.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

We did not observe any documented information in people’s care plans to support people being matched to staff. However, people, relatives and staff had a clear understanding of people’s preferences and preferred staff. For example, one person told us about the 2 male staff they like to work with and that they went to football and on trips together that matched their shared interests. One relative told us about their loved ones preferred staff, “[Staff name] they’re lovely and [staff name] has always been very close to [relative].”

We noted some staff had undertaken training on National Early Warning Score (NEWS) 2 but not all staff had received the appropriate training to effectively take and record people’s stats. NEWS2 is a score calculated using people’s temperature,

pulse rate, blood pressure, rate of breathing and responsiveness to assess how unwell they are and deterioration in their health. At the time of the assessment staff were not carrying these checks out and the provider assured us that further clinical support was being sought to provide staff with the right training.

Our observations showed there were enough skilled and knowledgeable staff available who worked well together to provide safe care that met people’s specific needs including when they required one to one support.

The provider had processes in place to assess and manage the risk of infection. However, staff had not consistently followed these ways of working so they did not always detect and control the risk of infection.

Food storage and disposal was not consistently followed. Frozen food was not labelled when it was frozen so staff would not know how long the food had been stored for and if it was still safe to consume. The inspection team found dried goods were not always appropriately stored and open items were not labelled and stored appropriately. This was addressed at the time of the assessment and items were thrown away where required.

The most recent food hygiene inspection recommended regular cleaning of the electric fly killer in the kitchen. However, this did not appear to have been completed regularly with the last cleaning taking place in August 2025 and the item was dirty.

Whilst there was no evidence that these issues had caused any harm it did place people at risk of harm from consuming contaminated or out of date food.

Overall, the standard of people’s personal hygiene, and hygiene in the home had improved which was supported by feedback from relatives meaning people were at a reduced risk of harm from infection.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

We reviewed documentation and records as well as the storage of medicines at Rosekeys. We found one gap in the medicines administration records of an individual, but the deputy manager was able to demonstrate that the medicine had been administered to the person but not signed for, this was addressed with the staff member involved at the time.

One person received medicines covertly, this means they are not always aware that they were being supported to take medicine to maintain their health and wellbeing.

There was a supporting protocol and necessary documentation in place to give this medicine safely and within the legal framework. We did note a care plan was signposted in the documentation, but the covering registered manager confirmed this care plan was not yet in place.

We saw evidence of engagement with medical professionals regarding people’s medicines which ensured people received the right treatment for them.

At the time of the assessment there were only 3 people living at Rosekeys, and they were supported by staff who knew them well. This significantly reduced the risk of harm to people presented by lacking or incomplete documentation and there was no evidence to support anyone had come to harm because of this. It was underlined to the provider that this issue needed to be addressed as ongoing gaps in documentation could present an increased risk should new people move in, and new staff join the team.