Rose Cottage Rest 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 as good. At this assessment the rating has remained as good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Falls, accidents and incidents were recorded. Falls were analysed to identify themes, trends and opportunities for learning; however, this process had not been consistently applied to all incidents. For example, incidents involving people expressing themselves verbally or physically were not routinely reviewed to evaluate whether staff responses had been appropriate, effective or in line with best practice. This meant the service could not be assured that all incidents were being used as opportunities for learning and improvement. Despite this, we observed staff responding appropriately when people became distressed and providing support in line with their needs. Following inspection feedback, the registered manager acknowledged this shortfall and advised that processes would be strengthened to ensure all incidents were reviewed and that learning was identified, captured and embedded into practice.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

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. The provider shared concerns quickly and appropriately.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

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 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. They did not always work together well to provide safe care that met people’s individual needs.

Staff had not always received training relevant to the needs of the people they supported. For example, some staff had not completed training in Parkinson's disease despite supporting people living with this condition. In addition, not all staff had completed training in areas such as positive behaviour support and diabetes care. However, staff demonstrated a good understanding of people’s individual needs, including the management of diabetes and supporting people when they became distressed. During the inspection, we observed staff responding appropriately and effectively when people experienced periods of distress, providing reassurance and support in line with their assessed needs.

We received mixed feedback regarding staffing levels within the service. While some people and staff told us there were enough staff available to meet people's needs, others expressed concerns about staffing arrangements. The local authority had previously identified concerns in relation to staffing during its 2026 review. The provider had recognised these concerns and had taken action to improve staffing arrangements and increase workforce capacity. The registered manager assured us the identified training would be booked and completed by staff by September 2026.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

People told us they received their medicines when required. We found some areas where medicines management required further strengthening to ensure medicines were always administered in line with prescribing instructions and recognised best practice. Whilst there was no evidence that people had experienced harm, we could not always be assured that medicines had been administered consistently as prescribed.

We found some inconsistencies in the administration of time-critical medicines, including medicines prescribed for Parkinson’s disease. Some medicines were required to be administered 30 to 60 minutes before food; however, guidance for staff had not always been readily available, and records showed occasions where medicines and food had been given at the same time. This meant the medicines may not have been as effective as intended.

We found staff knowledge of the specific requirements associated with some time-critical medicines was variable. We also identified occasions where medicines had been signed for before administration and, in some cases, left with people to take later. Although the people concerned had capacity to make decisions about their medicines, there was limited evidence of documented risk assessments and management plans to support these arrangements and demonstrate how any associated risks were being managed.

Some people had been prescribed transdermal pain-relief patches. Records showed application sites had not always been rotated in accordance with best practice guidance, which increased the risk of skin irritation and could have affected the effectiveness of the medicine.

There were also positive aspects of medicines management. Protocols for medicines prescribed on an ‘as required’ (PRN) basis contained guidance regarding the medicine to be administered, the reason for administration and the maximum dose permitted within a 24-hour period. We reviewed a person's Medication Administration Record (MAR) and found PRN medicines had been administered and recorded appropriately. Staff confirmed they completed appropriate training and had regular competency assessments when involved in the handling of medicines.

Following our feedback, the provider acted promptly to strengthen medicines management processes. A new system had been introduced to support the safe rotation of transdermal patches, and improvements had been made to the electronic medicines system to clearly identify time-critical medicines and provide staff with additional administration guidance. The provider demonstrated a positive approach to learning and improvement and was responsive in addressing the issues identified during the inspection.