Rose Hill Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 62 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Although some people said they knew who the registered manager was, others were unsure. Their comments included, “I don’t know who the manager is – I might recognise them if you pointed them out”, “I don’t think I know the manager”, “I’ve no idea who manages the place. It seems to run well so they must be good” and “The owner came in to see me today – got hold of my hand and asked how I was. I do know [them].” A relative told us, “The managers are approachable. They always say hello when I visit.” However, a relative expressed some anxiety following the recent admission of their family member. They told us, “This is our first visit. We don’t know who anyone is. It would have been welcome to have someone in charge to introduce themself.” We fed this back to the provider during our feedback.

The management team told us they ensured the staff were valued and promoted people’s individuality, protected their rights and enabled them to thrive. The registered manager stated, “In 2023, the provider changed. Massive improvements were made to rooms and the whole home. Staff feel more valued. The provider is also a nurse so understands that side. The staff feel supported now in a positive way. Now it is more than just work, get money and go home. It’s a positive place.”

Staff told us there was a good and positive culture within the home where people and staff had a good rapport, and the atmosphere was one of respect and care.

The provider set a culture that valued reflection, learning and improvement. The registered manager effectively used staff supervision and regular team meetings as a platform for staff to raise any concerns and an opportunity to share their views and opinions.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The registered manager had experience of working in health and social care. They were keen on developing the home to benefit people and the staff team. They received support from their line manager and had a good relationship with them. They told us, “My line manager is good and very supportive. The provider also is very good and supportive.”

Staff found the management team to be visible and supportive. They thought the registered manager was an experienced leader who was respected by all.

There were regular team meetings and management meetings where a range of subjects were discussed and information was shared.

In addition to team meetings, there were daily handover meetings to discuss important information, and any risks to service delivery. There were processes to support managers and senior staff in meeting their responsibilities.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People were given information when they moved to the home about how to raise a concern and said they knew how to make a complaint.

Staff said they knew about the provider’s whistleblowing policy and would not hesitate to use this to benefit staff and people living at the home.

The provider had processes in place to support staff to speak up. This included supervision meetings, handover meetings, staff meetings and a whistleblowing policy. Staff had also received training in safeguarding to reinforce their understanding and their responsibility to speak up.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us they enjoyed working in a diverse team. However, all staff had a good understanding of the English language and there were no reported language barriers.

The provider had policies to promote equality, diversity and inclusion and to protect staff from discrimination and harassment.

Staff who had healthcare needs were supported appropriately. The registered manager told us they met with them regularly to establish how they were feeling and how they could meet their needs within the workplace.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider had monitoring systems in place. However, these were not robust enough as they had failed to identify and address the concerns we found during our inspection, such as shortfalls in the management of medicines. This put people at risk of not having their pain and healthcare conditions effectively managed.

Processes to help ensure that risks to people were assessed and mitigated were not always effective. Risk assessments were not always in place where risks were identified or were incorrect. This put people at increased risk of harm.

For example, one person’s risk assessment dated 5 May 2026 stated the person was fully independently mobile. On 13 May, they had a fall and were admitted to hospital. The person returned to the home on 16 May no longer independently mobile. Their risk assessment had not been updated. Furthermore, their falls risk assessment stated the person was at ‘low risk of falls’. However, in the ‘action’ section, it stated they were at high risk of falls. The risk level on the risk assessment was incorrectly completed, as it recorded the risk as ‘low’, but the likelihood as ‘likely’ and consequence as ‘harmful’.

The same person’s weight chart indicated that since September 2025, they had lost 10kg. The care plan stated for staff to weigh monthly and record BMI and MUST score. This was carried out. The person’s care plan stated in May, the person’s weight was 83kg, however an audit carried out in the same month stated the person’s weight at 89kg. We discussed this with the registered manager who could not explain this discrepancy.

Two people were at high risk of developing pressure ulcers. Although a Waterlow score had been carried out and identified a ‘Very high risk’, no risk assessment had been put in place. A Waterlow score is a tool used to evaluate an individual's vulnerability to developing pressure ulcers.

A fourth person has ulcerated legs. These needed dressing weekly and we saw evidence this was happening. However, although there was a wound care plan in place, no risk assessment was in place to specifically address the risk of this condition. A generic risk of pressure ulcer risk assessment was in place.

One person was receiving their nourishment via a Percutaneous Endoscopic Gastrostomy (PEG). PEG feeding is a procedure that delivers liquid nutrition, fluids, and medicines directly into the stomach through a flexible tube inserted through the abdominal wall. It is used when a person cannot safely chew or swallow. Although this risk had been identified in the person’s care records, no risk assessment had been put in place.

Although we found no evidence people were receiving unsafe care, there was a risk that failure to maintain accurate, complete and contemporaneous records may result in people receiving inappropriate care and support because staff may not have correct and up to date information to meet people’s needs.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff told us they worked well with healthcare professionals to ensure people’s needs were met. The registered manager confirmed they had a good working relationship with a range of external professionals.

The provider had systems and processes to ensure people’s needs were reviewed with external professionals. The provider listened to feedback from them and where a need was identified, amended their policies and procedures to promote effective communication and partnership working.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Although some improvement in relation to quality monitoring had been identified at the last inspection, systems had not been embedded and sustained and similar concerns were repeated at this inspection.

The registered manager told us they listened to people’s feedback to make improvements. They had an action plan in place which was regularly reviewed and updated as actions were taken.

Staff told us the managers were always aiming to make improvements to the service to benefit people, and they enjoyed being part of this and felt consulted and involved.