Gringley-on-the-Hill care home placed in special measures following concerns over patient safety

The inspection at Rosekeys care home in November was prompted due to concerns the Care Quality Commission (CQC) received in relation to an incident reporting, safeguarding, management and staffing.

The facility in Gringley-on-the-Hill run by Lifeways Rose Care and Support Limited provides accommodation and personal care to people with learning disabilities and autism. The service can support up to 13 people but there were nine people using the service at the time of the inspection.

Greg Rielly, CQC deputy director of operations in the Midlands, said: “When we inspected Rosekeys care home, we were disappointed to see leaders didn’t understand the issues they faced resulting in a poor level of care being given to people in the service. This is because they didn’t understand the issues so couldn’t address concerns or put systems and processes in place to make things better.

“During our visit, we found people weren’t always safe from the risk of abuse. One person using the service reported that a member of staff threatened to remove their social opportunities if they didn’t behave well. There was another incident where someone was physically restrained but staff failed to follow the person's care plan, putting them at risk of harm. At the time, our inspectors were so concerned they spoke to the provider and the local safeguarding authority for investigation.

“Further incidents had also not been reported, for example, a person had sustained multiple head injuries following falls, some of these unwitnessed. The provider hadn’t reported these incidents which put people at continued risk of injuries from falls.

“On one occasion staff didn’t follow medical advice to take someone to hospital for checks. This led to their condition getting worse, and them having to make a potentially unavoidable trip to hospital. In another example, staff didn’t help a person access medical advice for their health condition, even though monitoring showed they needed it. This left people at risk of serious harm.

“Furthermore, there were serious environmental risks at the home. We saw electric heaters weren’t always at a safe temperature and a boiler room with exposed pipework was left unlocked putting people at risk of burns. We also saw a wardrobe wasn’t attached to a wall and could have been dangerous if it fell on people. Following our inspection team raising these concerns, the service rectified the issues.

“We have told Rosekeys care home where we expect to see rapid and widespread improvements and will continue to monitor them closely to keep people safe while this happens. We will return to check on their progress and won’t hesitate to take action if people are not receiving the care they have a right to expect.”

Following this inspection, the service’s overall rating has dropped from good to inadequate, as has the rating for being safe and effective.

The well-led rating has dropped from requires improvement to inadequate. As this was a focused inspection, caring and responsive were not included and remain rated good from their previous inspection.

A spokesperson for Lifeways Rose Care and Support Limited said: “We regret the findings of the CQC’s November inspection of Rosekeys, which were not consistent with the high standards we expect across the Lifeways Group.

“We have apologised to the people we support and their families. The safety and wellbeing of all those we support is our top priority.

“Our internal Quality Team had put in place an improvement plan prior to the CQC’s inspection and we have been working diligently, at pace, in partnership with Rosekeys, the local authority, and the CQC to implement the identified improvements. We are confident that people we support and their families will notice a swift return to the highest standards of care.”