The Rookery Care Home

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 regulation in relation to people’s safe care and treatment and governance at the service. We have asked the provider to take action to improve the service.

This service scored 47 (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. Lessons were not always learnt to continually identify and embed good practice.

The service did not have a consistent approach to learning from incidents or feedback. While some audits were carried out, there was limited evidence of how findings were used to improve practice. Staff told us they knew how to report issues, for instance with equipment. However, there was no evidence that any of the issues we found including with equipment had been reported by staff.

However, people and their relatives knew who the registered manager was and felt able to raise concerns if they had any.

This meant people did not get the best care from the service as they were not continually improving through reflection and learning.

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. Regular contact was maintained with the local authority, social workers, GPs, district nurses, and other professionals.

Where people moved in or out of the service, they were supported to ensure the transition was well managed. Staff were aware of the processes followed when someone transitioned into or out of the service and what they needed to do. One staff member said, “If they [a person] are coming from another care home [the management team] will go and assess them and put a care plan in place. They will then sit people down and say what the person's care needs are. We[staff]will read the care plans regularly and sign off that we have read them so we can help to get to know that person.”

This meant people experienced smooth, safe transitions between services, reducing risk and promoting continuity of care.

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. However, policies lacked crucial detail and risk assessments were either missing or lacked detail in certain situations which put people at risk of harm.

The safeguarding policy was out of date and inaccurate. It listed the incorrect safeguarding team as the contact and did not include local authority contact information. Although there was a step-by-step reporting guide, it did not mention the immediate safety actions staff must take to protect someone at risk. The policy also advised staff to challenge unsafe behaviour “when safe,” but gave no instructions on what to do when it was not safe to intervene, leaving staff without essential guidance.

Closed‑circuit television (CCTV) was used in and around the home, but there was no risk assessment in place for its use. The CCTV policy lacked required information, including relevant legislation and the defined purpose for recording. The registered manager told us the CCTV was used for security and to check incidents such as falls, yet staff were always present in the lounge, and there was no signage which informed people or visitors they were being recorded. There was also no accessible privacy notice explaining how recordings would be used or stored. This meant people’s privacy and dignity were at risk, and the lack of safeguards increased the likelihood of inappropriate use of personal information.

This meant people were not fully protected from the risk of harm because gaps in safeguarding processes and oversight created uncertainty about whether concerns were always identified, responded to, or managed safely.

Where safeguarding concerns had been identified, the provider had shared these appropriately, and investigations had taken place. Staff knew how to recognise and report concerns and felt confident to do so. People and relatives told us they felt safe with staff and the care provided. A relative said, “Oh yes, they [carers] keep them safe. They won’t ask for help, so they keep a close watch. Their last fall was a while ago. Their safety is in place. They have no bruises or sores. It can’t be faulted in any way. They’re proper carers and really care for them.”

The Mental Capacity Act 2005 (MCA) provides a legal framework for making decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to make decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under theMCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).The information wereviewed showed that staff were aware of the MCA and what it requiredand followed the correct processes.

Where people needed to be deprived of their liberty to keep them safe, the provider ensured a Deprivation of Liberty Safeguard (DoLS) was applied for through the relevant local authority. Any conditions related to DoLS authorisations were being met. The documentation supported that each DoLS application was decision specific for that person. We saw that the conditions of the DoLS had been met.

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.

The provider understood the importance of involving people and those close to them in managing risk and made referrals for Mental Capacity Act (MCA) assessments where needed. This helped ensure decisions made on behalf of people who lacked capacity were lawful and supported by appropriate advocacy. However, these positive practices were inconsistent and did not extend to all areas of risk management.

Most support plans and individual risk assessments identified key risks and provided guidance for staff. However, risks within the environment were not always assessed or managed appropriately. For example, there were pets in the building, including a parrot kept in the lounge. On the day of the visit, we observed the parrot outside its cage, despite the risk assessment stating it must be kept inside it. The risk assessment also failed to identify risks related to this pet and mitigation for risks associated with it

We found issues with Personal Emergency Evacuation Plans (PEEPs). One was missing, one was for an unoccupied room, and another had not been reviewed since 07 October 2022. This meant there was not always accurate information available to support people to evacuate safely in the event of a fire.

These issues had not been identified through internal audits or review processes, which limited the provider’s ability to recognise and address emerging risks. The registered manager acknowledged the concerns raised during inspection and began reviewing the affected areas to implement improvements.

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

There were locks on the outside of doors which could not be unlocked from the inside, creating a risk of people getting locked in rooms. There was a fire exit in a bedroom, but the key was kept in the manager’s office. This could not be located on the day of our visit. This would delay an evacuation. Personal Emergency Evacuation Plans (PEEP’s) records and the fire evacuation plan showed this was a fire exit used for that part of the building. There were no room numbers on doors which would make it hard for people to locate their own rooms but could also delay evacuation. We found evacuation equipment, including a chair and mats, not securely stored in designated locations. This posed a risk of harm due to potential trips, falls, or delays in evacuation if equipment was damaged or unavailable.

We observed people to be sat on pressure relieving cushions. However, some of these cushions were in a poor state of repair. We also found a damaged mattress. This was fed back at the time to the registered manager who advised they would order more cushions and change the mattress. This raised concerns regarding the effectiveness of the governance process about monitoring of both pressure cushions and mattresses.

We found scrap vehicles and discarded furniture in the car park, with personal protective equipment (PPE) stored in some vehicles. This posed a risk by obstructing emergency access and increasing fire hazards as the cars could not be moved. This meant people were at risk of coming to harm due to the environment not being kept safe. The provider acted promptly and removed the vehicles following our feedback.

The provider did not make sure there were enough qualified, skilled, and experienced staff. They did not always make sure staff received effective support, supervision, and development. They did not work together well to provide safe care that met people’s individual needs.

The training matrix used to monitor staff training was unclear and inaccurate. Some staff had expired training, others had no recorded training, and additional courses were poorly documented. Supervision records lacked detail and did not show whether sessions were individual or group based. Competency records were of poor quality, with no identified actions for improvement and unclear dates, which meant leaders could not reliably assess staff skills or knowledge. There were no systems in place to test staff knowledge following training.

People living at the home included those with epilepsy, yet there was no training provided for this care need. When asked, one staff member gave an incorrect response about how they would support someone after a seizure, which placed people at risk of harm due to delayed or unsafe intervention.

Recruitment practices were not safe or compliant with legal requirements. Several staff files were incomplete and had essential pre-employment checks missing. This included new staff and those who had moved into more senior roles.

Some Disclosure and Barring Service (DBS) certificates in staff files and others had no DBS record other than a receipt for a check to be completed, with no evidence certificates had been obtained or reviewed before staff started work. There were no processes for annual declarations or updates. These files also did not evidence if the DBS checks were clear or if there were disclosures which would need to be risk assessed prior to the staff members commencement.

There were also gaps in employment histories, with no evidence that these had been explored or verified. References were either missing, not from the most recent employer, or contained insufficient detail to confirm a person’s suitability for the role.

These shortfalls meant leaders could not be assured staff had the right character, background, or experience to work safely. The failure to follow safe recruitment procedures represented a serious breach of legal requirements and left people at risk because unsuitable individuals may have been employed without appropriate checks. Records also indicated staff had not all received appropriate training and knowledge checks. This meant staffing at the service could not be considered safe, and people were not protected from avoidable harm.

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.

We found various concerns throughout the home. Pressure cushions required deep cleaning or replacement as many were dirty and some had holes, placing people at risk of cross-contamination and infection. Copper waterpipes in various areas such as bathrooms were exposed, dusty, green in colour, and some had flaking paint. Bathrooms were not always maintained to an acceptable standard; toilet rolls were stored on cisterns, sealant was missing around flooring edges allowing dirt and debris to accumulate, and some fixtures including handrails and a bath hoist base were rusty. In many bathrooms, paper hand towels were missing from holders or placed on top of them. Lighting pull cords were missing cleanable covers, and some bins were not pedal-operated, meaning people and staff would have to touch the bins to open them.

This meant people were at risk of infection due to poor infection, prevention and control practices and ineffective infection control procedures and oversight. While the provider took action after these concerns were raised, we were not assured improvements were embedded or sustained.

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

Medicines were not consistently stored or managed safely. Prescribed topical creams were found in multiple bedrooms, all of which were unlocked, which meant people could access creams which were not intended for them. Some creams were not dated when opened, and although lockable cabinets were present, these were often left unlocked. This created a risk for people, including those living with dementia could apply or ingest medicines inappropriately.

The medicines fridge was left unlocked with the key in the door. Two creams inside had no opening date, and one had been dispensed in June 2025.There were no processes in place to record the times medicines for Parkinson’s Disease(which are time critical)were administered. For one person, handwritten times were documented on a printed copy of their medication administration record (MAR) chart, but this did not ensure consistency. Without accurate time recording, people with Parkinson’s Disease were at risk of preventable deterioration in symptoms such as tremors, rigidity, or increased falls.

On MAR charts, there was no record of the number of warfarin tablets administered, or whether the correct dose had been given. Additionally, 2 people had incorrect entries in the controlled drugs (CD) book for pain relief patches, recorded using the incorrect unit of measurement. One person’s pain‑relief patch was written down incorrectly which wouldn’t assist staff with knowing what the medication was, and some strong pain medicines were not recorded properly into the CD register in line with legislation. This meant there was a risk that staff might not know exactly what medicines had been given or were in stock and here was no assurance people received controlled medicines safely or accurately.

The medicine crusher appeared dirty, which posed a cross‑contamination risk. Audits of medicines were not consistently effective at identifying or rectifying issues. These issues put people at risk of harm from not receiving their medicines safely.