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R C Care Rosehill Ltd Inadequate

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating


Updated 1 December 2020

About the service

R C Care Rosehill Limited is a residential care home and is registered to provide personal care to up to 17 people, including those living with dementia. At the time of inspection there were 16 people living at the service.

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

People were at risk of avoidable harm and unsafe care.

Risks to people’s health, safety and welfare had not always been identified, assessed or managed. Where risks had been identified, they were not regularly reviewed, and appropriate action was not always taken to address them, including a delay in seeking medical advice.

Peoples care records did not contain enough information to enable staff to support them effectively. Staff did not have training in how to use equipment safely, or how to manage individual’s health conditions.

Staff were not always recruited safely and had been allowed to work at the service without the required pre-employment checks. There had been a significant staff turnover, and new staff were inexperienced and had yet to receive appropriate training. There were occasions where there were not enough staff to meet people’s needs, and the home did not consider peoples individual needs when deciding staffing levels.

People told us they felt safe living at the home, however safeguarding incidents were not always referred to the local authority or the Care Quality Commission. Staff told us they knew how to recognise signs of abuse but had not had safeguarding training. This put people at risk of abuse and neglect.

People did not always receive their medicines safely. Systems to ensure people received the right dose of medication were not robust and people did not always receive newly prescribed medication in a timely manner. Some improvement to record keeping was needed, for example where people were receiving non-prescribed medications on a regular basis.

The premises did not always keep people safe. One person regularly left the building when unsafe to do, which put them at risk of harm. A safeguarding concern had been raised previously, however the action taken as a result of that concern was not effective in preventing the person continuing to leave the building.

A lack of analysis of safety and safeguarding incidents meant lessons were not learnt when things went wrong. Following this inspection, we raised two individual safeguarding concerns.

We have signposted the provider to resources to help develop their approach to preventing and controlling infection.

The registered manager had made some positive changes to the service, and people told us they were happy, however, there were significant shortfalls in service leadership. Quality assurance reports and action plans provided to the Care Quality Commission following the previous inspection failed to identify or address the concerns we found at this inspection.

Audit and monitoring systems were inadequate. Information was not analysed, and the provider did not undertake any quality control audits or checks. Many people had been admitted to the service during a period where the registered manager was new to post, there was a high staff turnover and the home faced the challenges of the early stages of the Covid-19 pandemic.

The lack of quality assurance systems and analysis of current performance meant the service was not continuously learning or driving improvement. Current best practice and information was not being used to improve quality.

There was limited partnership working with other agencies, and records did not demonstrate an open sharing of accurate information or a good understanding of where partnership working might be beneficial to people.

People and their families told us the registered manager was caring and improvements had been made to the atmosphere, culture and approach of the home. However, there were still indications of people fitting into routines to suit the staff, and times where staffing levels did not e

Inspection areas



Updated 1 December 2020

The service was not safe.


Requires improvement

Updated 1 December 2020



Updated 1 December 2020


Requires improvement

Updated 1 December 2020



Updated 1 December 2020

The service was not well led.