Rosekeys

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that leadership, management, and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment, the rating has remained requires improvement. This meant there were shortfalls in leadership around the governance of the service which did not assure the delivery of high-quality care.

The provider remained in breach of Regulation 17, Good Governance at this assessment. We have asked the provider for an action plan to address the risks identified.

This service scored 61 (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 shared vision, strategy, and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The service had experienced a high turnover of management in the home. The current registered manager was working with the staff team to make improvements to the culture at the service and ensure everyone was working towards the shared goal and shared direction to ensure each individual person was at the centre of their support when decisions about their lives were being made. This was an ongoing piece of work and not fully embedded, but the inspection team did note improvements from the last assessment.

We spoke with the registered manager about the culture of the service, they told us, “Although there is still work to do the team as a whole things have been so much better and that’s a real credit to them [staff]. They are listening more engaged and understanding, things have changed.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience, and credibility to lead effectively. They did so with integrity, openness, and honesty.

We spoke with the registered manager, regional manager and members of the senior leadership team who all communicated their commitment to making and embedding improvements at the service and ensuring the correct resources were in place.

The registered manager had the right skills and experience to lead the team and felt supported and encouraged by their line manager, and the senior leadership team, both personally and professionally. They were open and honest and demonstrated the values of the organisation.

Observations of people and staff interactions with the leadership team evidenced they had the knowledge to lead effectively.

The management team were working on developing the culture at the service to ensure greater focus on how they could enable people to live a good, ordinary life as part of their community. The registered manager was keen to support staff to learn and develop their skills and understood that this would be an ongoing piece of work, they said, “That quality of care you can’t learn overnight it has to be taught, and it has to stick.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Relatives told us they felt they could approach the manager with any concerns. A relative told us, “I am very happy with the manager. They are good. I can see them and have a chat when I want.”

We did not receive any information of concern that would indicate people or staff were unable to speak up, or that they wouldn’t be listened to and responded to appropriately. The provider had an appropriate policy to guide staff on whistleblowing. At the time of our assessment, the service only supported 3 people. We did not see any information in an accessible format for people living at the service who would benefit from this should they wish to raise a concern. However, the registered manager had a good understanding of how to provide information in different formats so that people could understand it and underlined that this would be implemented if a person(s) moved into the home that would benefit from this.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance, and outcomes, or share this securely with others when appropriate.

There was an inconsistent approach to governance processes and staff were not always clear about their responsibilities and the processes to oversee this had not identified and addressed these issues. Information requested by the inspection team was not always readily available and staff gave conflicting accounts about information and processes.

Processes had not been implemented and embedded effectively and had failed to identify and address issues for example: inconsistencies of information in care plans and issues with the environment. The current management team told us they were committed to making improvements and embedding these improved ways of working. They made changes through the assessment process to demonstrate how this would be achieved, for example improving the information in care plans and adding a clear daily handover of information to guide staff practice. They were effectively using the current system to record and oversee accidents and incidents to support good governance at the home. The provider remained in breach of good governance regulation, and we have asked the provider for an action plan to improve this.

The registered manager spoke with us and said, “A lot of it was also the fact there was a lot of different managers and staff didn’t have a fair go, where they could have had learning and development from mistakes and addressed knowledge gaps, we have now been able to explain things to them. They didn’t know things were a risk. They should have been taught things in the first place and been given that knowledge.”

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information with partners and collaborated for improvement.

We reviewed evidence that the provider engaged others so people could thrive and have new experiences. One professional working with the service told us, “We have found the new management seem to have been very responsive to most suggestions that we have made, or guidance given during our visits to the placement. They are both usually responsive also to any email/telephonic communication.” They also noted that they are copied into communication with relatives of the person they are directly involved with where appropriate to do so.

The provider did not always focus on continuous learning and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome, and quality of life for people. They did not always actively contribute to safe, effective practice and research.

On 23 April 2025, we took urgent action and asked the provider to mitigate the risks identified at this assessment. Some of these issues had previously been identified through internal and external processes but had not been addressed. This indicated a failure in the provider’s governance processes and a lack of learning from previous issues raised.

The provider responded promptly with a clear action plan to tell us what they would immediately do to ensure people are protected from the risk of harm. They also provided some additional comments and evidence to support work that had been completed. A further visit to the home and documentation provided evidenced that work had been carried out and other areas for improvement, specifically in the environment, were underway.

The provider had implemented a digital system for people’s care plans, risk assessments, daily records, and other associated information. This system wasn’t embedded at the service but staff feedback about using the system was positive and there is recognition of improved data protection when using a digital system. The registered manager told us they were getting some additional support with implementing the system effectively, “I met with another area manager last week who has been using Nourish since 2020, it was really helpful with their support I been able to redo [name] support plan”.