Rushymead Residential Care Home in Coleshill, Amersham, has been rated ‘requires improvement’ following an inspection by the Care Quality Commission (CQC).

The home provides personal care for up to 28 older people, some of whom are living with dementia. When the CQC inspected in November 2023, 22 people were living at the service.

What inspectors found


According to the CQC’s report, residents at Rushymead were not routinely protected from risk of injury or avoidable harm.

Risks associated with fire were not always identified by the registered people, or acted upon when they were made aware. Fire risks identified by the provider’s own fire risk assessment in March 2023, and by Buckinghamshire Fire and Rescue Service, had not been actioned by the provider in a timely manner.

People were also left at risk of potential abuse, and staff did not always recognise when abuse had occurred. Inspectors heard about incidents of physical assault and intimidation, and incidents where residents had entered another person’s room without permission. These had not always been referred to the safeguarding authority or investigated by the provider in order to prevent a reoccurrence.

Inspectors found that people were also put at risk by poor recruitment processes and systems. The registered manager and provider did not ensure all the required pre-employment checks were completed before staff worked with people.

People were at risk of infections due to poor hygiene and a lack of preventative measures to stop or prevent them. The CQC also reported that Rushymead Residential Care Home failed to ensure all accidents and incidents were recorded, investigated and analysed. This meant that trends could not be easily identified.


Inspectors found that Rushymead was not well led.

Both the registered manager and provider failed to ensure they maintained compliance with regulations. The CQC did not always receive the required legal notifications of certain events, such as those related to safeguarding and serious injury.

Inspectors found the care records within the home to be disorganised, unclear, and not complete or accurate. For instance, some records showed a lack of hydration and personal care offered to people. They also found that confidential records relating to staff and the home management were easily accessible to unauthorised people.

The CQC has made a recommendation to Rushymead about ensuring people are referred to external healthcare professionals in a timely manner, in order to prevent deterioration in their health.

Feedback from people and their families

People using the service told the CQC that staff were kind and responded to them when they pressed the call bell. Relatives gave inspectors mixed feedback.

People were not always supported to have maximum choice and control of their lives. However, staff supported them in the least restrictive way possible and in their best interests.

Inspectors found that improvements were required in the policies and systems at the service to ensure that, when people’s movements were restricted, legal authorisations were in place.

From ‘good’ to ‘inadequate’

The CQC’s inspection of Rushymead was prompted by a review of the information it held about the service. The CQC had been told of concerns regarding governance at Rushymead and how well people were safeguarded. It was therefore decided to conduct a focused inspection that focused on the key questions of whether the service was safe and well led.

For the key questions not inspected – whether the service is effective, caring and responsive – Rushymead’s rating remains the same as at its previous inspection.

The overall rating for Rushymead Residential Care Home has gone from ‘good’ to ‘inadequate’ following the November 2023 inspection, based on the CQC’s conclusion that both safety and leadership are inadequate at the home.

You can read the CQC’s full report on the provider on its website.

Have your say

Don’t forget – if you or a loved one has experience of care from Rushymead Residential Care Home, you can rate and review the service right here on our website.

Feed back now

Published on 10 Jan (updated 27 Mar)

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