Rosehill House

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 inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to good governance, including leadership, quality assurance, learning and improvement, and culture.

This service scored 36 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. Risks were not always acknowledged, assessed and mitigated and whilst people felt safe and were supported by staff who knew them well, safety was not prioritised. Leaders were not able to demonstrate a focus on learning and improvement as incidents were not analysed for themes, trends or learning.

The provider said, “I know I’ve taken my eye off the ball, I don’t have a service improvement plan, it’s all in my head.” This meant there was no formal strategy in place to address risks and monitor progress.

The provider did not understand the context in which they delivered care, treatment and support. Insufficient oversight and governance had affected the overall quality and standards at the home. There was a lack of knowledge around the issues we identified in the service, including safety, mental capacity, risk management and robust oversight. The provider was not prioritising the quality and safety of the care and support provided for people or staff. The provider, who was also the registered manager said, “I am the registered manager, and I need to resume acting as such and look at how we move the service forward.”

People, relatives and staff felt able to speak up. However, systems were not in place to support the formal sharing of feedback. There was insufficient evidence that concerns were robustly investigated, outcomes shared, and improvements made.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

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

Significant and widespread concerns were identified during the assessment, which had not been identified by the providers quality assurance and governance systems. Systems had not been effectively implemented to assess, monitor and mitigate risks relating to the health, safety and welfare of people. Audits were not robust and failed to adequately assess, monitor and improve the quality and safety of the service.

Robust arrangements for the availability, integrity and confidentiality of information and records were not in place. There was a failure to maintain an accurate, complete and contemporaneous record of each person’s care and support.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider attended various meetings and were a part of a range of online forums to keep up to date with best practice.

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

Audits were not effective or sufficiently robust to ensure learning and improvement. There was a lack of provider oversight in ensuring risks, and areas for improvement were identified and actioned. There was a failure to ensure a robust focus on learning and improvement was in place.