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 remained requires improvement. This meant people were not always safe and protected from avoidable harm.

The provider remained in breach of Regulation 12, Safe Care and Treatment at this assessment. We have asked the provider for an action plan to address the risks identified.

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.

The provider did not always have a proactive and positive culture of safety. Staff did identify concerns about safety of the environment, but they were not always escalated and effectively responded to. Staff did report safety events which were reviewed by the leadership team to identify patterns. Lessons were not always learnt to continually identify and embed good practice.

We found issues identified through internal and external processes were not consistently responded to, and lessons had not been learnt to ensure the issue did not recur. For example, a fire risk assessment carried out the previous year identified concerns that had not been addressed. This put people at risk of harm in the event of a fire.

The provider and registered manager were open and honest and aware of their duty of candour. They took on board feedback and responded promptly to concerns.

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 referrals to healthcare professionals as well as social workers and other professionals involved in people’s care and support. We noted the appropriate professionals had been contacted to highlight issues about changes in people’s health and wellbeing and advice and guidance was being followed.

This approach meant people received continuity of safe care and support that met their needs.

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.

Restrictive practice, for example, locked doors and restricted access to certain areas of the building, was being used, was legally justified, proportionate, necessary and as a last resort. For example, to allow a person privacy without compromising their safety, a discreet monitoring device was in use which was detailed in the persons care plan and the correct authorisation for using this was in place.

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. This information was recorded in their care plan.

Staff had received training in safeguarding and the provider had a current policy document in place to guide staff.

During the assessment we did observe some concerns regarding people’s safety which presented a risk of harm which could have resulted in a safeguarding concern. We discussed these issues with the management team and the provider who took immediate action to address these concerns.
 

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them however this was not consistently documented effectively.

Care plan documents did not evidence how people, or people important to them, were involved in conversations and processes to understand and manage risk or detail when people could not be involved in these processes as they may cause the person to become distressed.

We discussed this with the registered manager who addressed a specific point regarding a person’s nighttime support and further to a meeting with the person’s social worker and family member provided evidence of them being involved in this process.

People who communicated their needs or expressed feelings or emotional reactions through distress behaviours had a care plan in place that identified this. The registered manager told us they were in the process of updating these plans to include more information to aid staff to better support people. For example, providing additional detail about the person’s usual presentation and what they may do differently during periods of anxiety or distress, and how staff should respond to this to support the person to manage any risk to themselves or others.

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.

We found the environment was not always safe. We observed rooms used to store broken furniture and other items not in use were unlocked so were accessible to people. This placed them at risk of harm from trips and falls as well as from injury from sharp or falling objects. The home was not safe in the event of a fire. We observed issues with fire doors including a door which led to someone’s bedroom that was kept in the locked position due to a broken door handle, so it did not close and would not protect the person in their room if a fire broke out. Issues relating to fire safety were also identified at the previous inspection.

We contacted partners in the fire protection team who carried out independent checks at the home which also identified recommendations for improvements of fire safety in the home.

The provider had processes in place to maintain a safe environment however these processes had not effectively identified concerns found by the inspection team. Some processes were completed by external contractors including checking the water temperatures and legionella checks which were found to be completed consistently.

Improvements were required for internal processes and carried out consistently to ensure people’s home environment remains safe. The provider was quick to respond to concerns regarding safety and evidenced they had cleared external rubbish, broken furniture and other items from rooms not in use and replaced/repaired doors as required. The registered manager implemented a full fire risk assessment and evacuation plan in addition to individual emergency evacuation plans to clearly guide staff how to respond. We also noted whilst on-site that contractors were carrying out work in response to the fire teams findings.

The provider made sure there were enough qualified, skilled, and experienced staff, who received effective support, supervision, and development. However, staff practice did not consistently demonstrate they worked together well to provide safe care that met people’s individual needs.

We reviewed records of staff training and observed that there were enough staff available to provide people with the correct level of staff support to meet their needs. During the assessment we observed an instance of poor staff practice when supporting a person with moving and positioning. Staff failed to use the correct equipment and safe practice. The inspection team intervened and requested a manager supported the staff. This was discussed with the provider and the management team on site at the team who immediately implemented staff retraining and assessment of staff competency.

People and relatives did not have any concerns regarding staffing. One relative told us, “I think there have been enough staff the last few times I have visited. They seem to support [relative] well.” Our observations indicated there were enough staff to support people including supporting them outside of the home.

When people received one to one support the registered manager, and people themselves, had identified staff with skills and experience matched to the needs and preferences of the person which enabled people to work towards and achieve their aspirations.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

We observed staff supporting with personal care were not using the appropriate personal protective equipment (PPE) to carry out this task. The manager on site immediately addressed the concerns regarding staff use of PPE.

We saw communal areas were clean however people’s personal space was not always hygienically clean. For example, we saw a safety mat at the side of a person’s bed was soiled and damaged.

During checks in the kitchen, we found items in the fridge were not appropriately labelled to indicate when they had been opened. Staff disposed of these items at the time.

People were supported with their personal hygiene, which was documented in their care plan, however, the daily records did not consistently provide clear evidence of this. Our observations of people’s clothing and presentation indicated people had been supported with personal care.

Relatives did not voice any concerns about the cleanliness of the home or people’s personal hygiene. One family member said, “It’s very homely, clean.”

Failing to maintain a hygienically clean environment and use the correct PPE placed people at increased risk of infection.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. Staff had not involved people in planning, including when changes happened due to this being a potential trigger for anxiety, but relatives were kept informed of changes.

The medicines room was secure, clean, and tidy. Fridge and room temperature checks were completed consistently, and medicines were stored appropriately with stock stored safely. We noted the controlled drugs cabinet was not attached to the wall, but there were no controlled drugs in use at this time and the management team advised this was being corrected further to feedback from a recent medicines audit.

Medicines records were paper-based, we found no gaps in recording. We observed evidence of engagement with professionals regarding a person’s medicines being reduced and this had been actioned in line with the prescriber’s guidance. Body maps were in place where people were supported with the application of topical creams and the provider had a flammable creams risk assessment as required.

The provider had a current policy which was available to staff in paper format in the medicines room and had provided staff with training to be able to safely support people with their medicines.

This meant people were safely supported with medicines to ensure their health and wellbeing and staff had appropriate guidance on how to do this in line with people’s needs and wishes.