Rosebank Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

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

This meant people were safe and protected from avoidable harm.

This service scored 63 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. However, some improvements were needed in this area and the new systems, processes and new management structure implemented needed further embedding to ensure effective oversight and lessons learned. The management team were honest and open throughout the assessment and committed to improving outcomes for people living at the service.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. Action was taken to address concerns we identified with care records to ensure information shared internally or with external parties was accurate, up to date and supported safer more consistent care pathways. Records we viewed evidenced good working relationships and timely referrals.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Systems and processes were in place to ensure people were safeguarded from the risk of abuse. People and their relatives told us they felt safe. One person told us, “I feel safe here.” A relative commented, “We have no qualms about the home.” Records showed safeguarding concerns were reported promptly to the local authority, but not all were reported to CQC. We discussed this with the registered manager who agreed to action for all safeguarding concerns. Staff received safeguarding training and understood how to recognise and report poor care and abuse. Staff told us they knew how to raise a concern and were confident their concerns would be listened to and acted upon. One staff member told us, “I would report it to my manager and document it.” Another staff member told us, “[I would] report my concerns to senior staff, manager. Document my concerns, date, time and to whom it was reported to.” People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that the provider was able to identify when people were potentially being deprived of their liberty, complied with the basic principles of the Act, and made applications or/and urgent authorisations in a timely manner.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Care records for some people contained inconsistencies or lacked sufficient detail to guide staff effectively and ensure risks were properly managed. For example, 1 person’s care plan required updating across all relevant sections to accurately show that bedrails were no longer in use. Records of care provided were also not always completed consistently, meaning there was not clear evidence that support had been delivered in line with people’s needs. For example, some records of fluid intake or repositioning were not recorded, restricting the ability of managers to have clear oversight. These were recording concerns and we found no evidence of harm to people. The registered manager had already identified gaps in care records and agreed to prioritise updating of records and ensure accurate recording of care provided. Staff knew people well and were able to explain how they minimised risks. One staff member told us, “There are risk assessments in each individuals care plan which outline risks associated with their care. This is reviewed monthly and staff are to follow this to ensure safety.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The home was tidy, well maintained and safe. In places flooring was stained despite regular cleaning. Plans were in place to replace this with more suitable flooring that could be cleaned more effectively. One relative told us, “The room is always clean and tidy, and I am impressed with the amount of cleaning that goes on there.” Systems were in place to ensure regular health and safety checks were completed. Information in one emergency grab bag required updating but this was actioned immediately and a revised system put in place to ensure in future this was updated without delay.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. Some staff had not completed all required mandatory training or refresher courses, resulting in training compliance levels being lower than expected. The registered manager was aware of this and had implemented a revised training schedule for face-to-face training for all staff to come up to date. They confirmed that in the meantime each shift always had trained staff available. Staff had also not consistently received regular supervision sessions or annual appraisals. The registered manager had identified this shortfall and introduced an improved system to ensure all staff receive both supervisions and appraisals in 2026. Recruitment procedures were in place, so people were cared for by suitably qualified staff who had been assessed as safe to work with people. However, it was noted that employment history for some candidates did not always provide sufficient detail or include all information from leaving school. No concerns were noted with staffing levels and people and overall staff felt that staffing levels were safe and where necessary short notice cover provided. One relative told us, “Yes, I feel there is always enough staff on duty. You can always find a senior to speak to if you need to.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The provider had an infection, prevention and control (IPC) policy and training was available for staff. Processes were in place to ensure people were protected from the risk of infection. Personal protective equipment (PPE) was available throughout the building, and an additional sluice room had been installed downstairs. Relatives were complimentary of the cleanliness of the home. One relative told us, “One thing I like about the home you do not go into it, and it smells of urine. There is always a nice smell there.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Medication administration records (MARs) did not showanymissed dosesand stock levels were correct.When people were given an ‘as and when required’ (PRN) medicine PRN protocols were in place. However, records of the effectiveness of these medicines were not being recorded to inform staff for future administration. Where people regularly refused a medicine or were asleep at the time of administration clearer recording of action taken was needed including any referrals to health professionals as well as clear guidance for staff to follow. Risk assessments for paraffin-based creams were also required to address the potential hazard of these products transferring onto clothing and increasing flammability. The registered manager agreed to address all these issues immediately. Staff were trained in medicines administration, and their competency had been assessed. People were supported by staff who followed systems and processes to administer, record and store medicines safely. Regular medicines audits were carried out to ensure systems remained safe.