Liverpool care home plunged into special measures

Roseside Care Home in Netherley, run by Exemplar Health Care Limited, provides personal and nursing care for up to 32 residents, including some who live with dementia and/or other mental health conditions.

However, following their first inspection last September, officials from the Care Quality Commission (CQC) have expressed grave concerns at how residents were being treated. As a result, the Vancouver Road location has been graded as inadequate and will be kept under review.

CQC inspectors have now issued Roseside bosses with a warning notice in order to focus their attention on making rapid and widespread improvements in a series of areas, having found the service did not adequately assess people’s needs and risks or safely manage medicines.

The culture at the home for some people was restrictive, the report said. The report, released today, said some of the dozens of residents experienced “intrusive checks and restrictions” including some facing physical restraint to control their movements and behaviours, which may have been avoidable had suitable positive behaviour support plans been in place.

Concerns about the use of restrictive interventions were reported to Liverpool Council by CQC during the inspection. The report added how some people and staff experienced repeated verbal or physical abuse from other people living in the home.

It said: “The service will be kept under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements. If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures.

“On another occasion, officials found one person’s clothes were locked in a cupboard outside of their bedroom. There was no evidence the decision to remove this person’s clothes from their possession had been consented to, by them or subject to a mental capacity process if the person lacked capacity to consent.

“People’s care plans and risk assessments did not always contain consistent or enough information to guide staff on how to mitigate risks specific to them. For example, one person was at significant risk of urinary tract infections but there was no specific risk management plan in place to advise staff how to support them.”

It found one resident at risk of choking was given unsafe foods to eat according to one set of records, while medicines were not kept safely. Some could not be signed for at the time of administration because staff administering them used a fixed, desktop computer, situated in the nurses’ office to sign, rather than a portable laptop that they could take with them on their round.

Nurses signed for creams that they had not applied or witnessed being applied, because creams were applied by care staff. In one instance, one resident didn’t receive the correct cream needed for an entire month.

Karen Knapton, CQC deputy director of operations in the north, said: “When we inspected Roseside, we were concerned about their ability to provide the specialist care needed for the people who called it home.

“Staff didn’t understand or implement the Mental Capacity Act properly and people experienced intrusive checks and restrictions on their day to day lives without appropriate authorisation in accordance with deprivation of liberty safeguarding legislation.

“We found one person experienced avoidable diabetic complications due to poor monitoring of their blood sugar levels, while another person’s prescribed creams weren’t applied as they should have been due to poor processes. While staff did their best to be kind and caring, some processes like care plans didn’t always support them to understand and meet residents’ needs.

“The care plan of one person at risk of choking, hadn’t been updated with guidance from the dietician, and they had been given unsafe foods to eat as a result. However, care plans did include information on personal equality and diversity characteristics, to ensure it was respected.”

“We expect Roseside to make rapid and widespread improvements, and they are now in special measures so CQC can check people are safe while that happens. Leaders know the areas where improvements are needed and CQC will return to check on their progress.”

A spokesperson for Roseside said: “We are deeply disappointed with the Care Quality Commission’s (CQC) report, as we believe it does not accurately reflect feedback provided during the inspection in September 2024, testimonials from people living in the home and our team, or discussions with other health and care professionals.

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“We have submitted a formal complaint to CQC regarding the process and a detailed factual accuracy challenge in response to the report’s findings.

“We remain firmly committed to ensuring the highest standards of care for the people living in our home. Following the inspection in September 2024, we reviewed the report in detail and, where appropriate, quickly implemented improvements.

“To provide further assurance, we commissioned an independent inspection by Coach4Improvement, a respected and experienced organisation with expertise in the CQC regulatory process and standards. Their findings indicate that care at the home meets the requirements for a ‘Good’ rating – well above the CQC’s determination – using the current CQC single assessment framework.

“We are confident in the quality of care provided at Roseside and have invited CQC to return at its earliest convenience to reassess the home. We appreciate the positive feedback shared by the people we support and their families and thank them for their patience as we work through this process.”