Rosehill House

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 changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to governance and oversight, including the environment, risk management, staffing and culture.

This service scored 38 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Safety incidents, such as falls, were not analysed to identify themes and trends, learning and mitigation to minimise future risks. A safeguarding log had recently been introduced, however there was no evidence of learning from safeguarding investigations. Premises safety was not reviewed, and risks were not identified and acted on. Health and safety risk assessments were not always current, did not always include control measures and action was not taken to learn and embed good practice.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

People’s safety was not robustly monitored or managed. Risk assessments were not always adequate, and some risks had not been assessed appropriately, reviewed or mitigated. Hospital passports had either not been renewed or updated after use or were not in place at all.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

People told us they felt safe. However, limited information was recorded in relation to safeguarding concerns. Allegations of abuse notifications were submitted to CQC however, these related to falls rather than abuse so we could not be sure of the providers understanding of safeguarding. A staff member said, “We have been unsure what to report to safeguarding. We were only reporting unwitnessed falls, head injuries and serious injuries. We were only advised to send in all the issues when safeguarding visited recently.”

The provider did not work well with people to understand and manage risks.

Risk assessments were of varying quality, and some had not been reviewed within the providers set timescale. There was limited information for staff to follow in the event of incidents. There was no evidence people, or appropriate others had been involved in the assessment and mitigation of risks.

Fall records often contained minimal information about any injuries and any action taken. It was not always clear if additional action had been taken to follow up on unexpected bruising. There was limited direction for staff to follow in relation to untoward events and more detailed documentation was needed.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Risk assessments for windows were in place and had been consistently reviewed as appropriate. However, window restrictors were not in place and catches did not comply with the Health and Safety Executive guidance on health and safety in care homes.

A risk assessment regarding the open staircase was in place and focused on the fabric of the stairs. The potential risk of people falling down the stairs had not been assessed.

Several tall items of furniture in people’s rooms had items stored on top of them and were not fastened to walls which posed a risk. Whilst it is not a legal requirement to test all portable electrical appliances every year, a decision should be made on the level and frequency of maintenance needed according to the risk of the item becoming faulty. Some equipment did not have PAT testing labels and others were out of date. No up-to-date list was available during the inspection, and we were told, “It’s at the home of the handyman, new stickers are due to be put in place.”

Professional fire checks were completed, however some in house checks had not been completed for a month. Health and safety audits were completed, and it was documented that fire exits were clear however this was not sustained and on both days of inspection we found items being stored in fire exits, including weighing scales and a hoist. This compromised evacuation routes and presented a significant risk in the event of a fire.

Health and safety risk assessments were completed however many were dated 2004, inadequate reviews had taken place, and not all risk assessments contained adequate control measures. The laundry room contained an excessive amount of storage which posed both a fire risk and an IPC risk as the area could not be adequately cleaned. Whilst a risk assessment was in place, dated 13 February 2024, no control measures were documented, nor was any action recorded as needed to minimise risks.

The provider did not make sure there were enough safely recruited, qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

There were mixed views about staffing levels. A dependency assessment was used to calculate staffing levels; however, some people were assessed as needing only 1 minute of support at breakfast and lunch but 10 minutes at teatime with no reasoning for the disparity. A person said, “I think they are possibly short staffed.” Relatives said, “They are always busy and rushed off their feet. They work very hard and so yes, they could do with more staff” and “There are not enough staff on at weekends.” Staff comments included, “The owner tells us there is (enough staff). Sometimes it feels as if there isn’t” and “I think there are enough staff, we have relief staff or we try and pick up shifts. Bank staff don’t always pick up shifts though.” Some concerns were raised in relation to supporting people who needed 2 staff which left the floor with minimal cover.

Recruitment processes were not robust. It was not always evident that staff’s previous employment history had been checked, and references were not always followed up, documented or verified.

Staff training was provided which consisted of Elearning and some face-to-face training. Staff supervision meetings were held, however dates on minutes did not coincide with those on a supervision log.

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 home was generally clean and tidy. Some ensuites were wallpapered which made cleaning more difficult and shared bathrooms had cloth towels for communal use, however electric dryers were due to be fitted. Some pedal bins were missing foot pedals and did not open correctly, but action was being taken to replace them during this assessment. Audits were completed regularly and staff understood how, and when to use Personal Protective Equipment (PPE) to reduce the risk of infection.

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.

Some handwritten Medicine Administration Records (MARs) were used. These were detailed but best practice guidance had not been followed as they had not been double signed to ensure accuracy. There was no system in place to ensure topical medicines (prescribed creams and ointments) were applied as prescribed. Some staff told us they did not record the use of creams as it was done every day.

Staff completed online training and had their competency assessed on an annual basis.