Rosebank Care 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 good. At this assessment the rating has changed to 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.

This service scored 57 (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. However, stronger teamwork and more effective communication was needed to ensure required improvements were implemented promptly. For example, some staff were reluctant to complete certain training and arrangement of face-to-face training had taken time which affected compliance and, potentially, safe care. A plan was now in place to address this, but its success relied on full engagement from all staff. The registered manager was knowledgeable about their regulatory responsibilities and plans for the service.

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. Over the past 6 months the provider had introduced a new management structure, and a new registered manager had been appointed, who also held responsibility for another care service. An action plan was in place and being progressed by the registered manager; however, some areas needed more timely action. Ongoing monitoring and review of the new structure was needed to ensure that it was effective, supported appropriate oversight by the registered manager and enabled identified changes to be implemented promptly and consistently.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The management team sought feedback about the service through surveys, meetings and reviews, involving people, those close to them, staff and other professionals. The provider had clear information in place for people and for staff on how to raise concerns, including clear complaints and whistle blowing policies. Staff knew how to raise concerns and overall told us they felt any concerns raised would be addressed appropriately. One staff member told us, “My suggestions or issues are well listened and attended to.” Another staff member told us, “Yes, I would be happy to make suggestions, and I am confident they will be listened to.”

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. However, improvements were needed to the frequency of supervision sessions and provision and completion of mandatory training and appraisals to ensure staff had the necessary support and skills to care for people effectively. We received assurance from the registered manager that a plan was in place to address the backlog in training, appraisals and supervision.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. However, we found some concerns in relation to the quality of some care records, support for staff and medicines. Although there was no evidence of impact to people and plans were in place to address these concerns, action could have been more timely to reduce any potential risks to people. Where we identified shortfalls, the registered manager agreed to set timescales for completion. The registered manager was aware of their responsibilities to notify partners of notifiable incidents but was not always submitting all required notifications to CQC. The registered manager agreed to address this immediately. We received positive feedback from people and families about the service and the management team. One relative told us, “I see the manager around a lot, and they are very approachable to you.”

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. The registered manager had a strong commitment to improving the service and was open to suggestions for improvement and recognised the importance of joint working with partner agencies. Records seen evidenced positive working relationships with other partners and professionals. Advice was sought, and referrals were made in a timely manner which promoted continuity of care. One professional commented, “We currently do not have any issues with Rosebank care home as we find them receptive and proactive. Also, I have found them to be respectful, caring and dignified when caring for patients at the end of their life.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. However, new governance, audit and reporting tools introduced still required time and consistent application to become embedded across the service to ensure effective oversight as well as learning from events. The registered manager was open and transparent throughout the assessment and demonstrated a clear commitment to making the required improvements.