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 inadequate. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

Although improvements had been made in reporting and investigating safety events, further improvements were still required to ensure the service could analyse themes and trends from incidents and that lessons learnt was shared with staff.

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

Although improvements had been made with how the service worked with healthcare partners to manage people’s safety, procedures in place to aid transitions between services were still not always effective. For example, pre-admission assessments were not always available and DNACPR records did not always contain consistent information.

The service 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.

Safeguarding incidents were investigated, and immediate actions were taken to safeguard people. Concerns were referred to the appropriate authority where required. However, improvements were required to ensure learning from safeguarding incidents was shared with staff to reduce the risk of recurrence. Audits of safeguarding incidents hadn’t identified learning wasn’t being shared

Staff had received safeguarding training and knew how to identify and report abuse. One staff member told us, “If I witnessed abuse such as people being shouted at or staff neglecting people, I would talk with a senior or manager. I think people living here feel safe and they like the staff.”

There was an up-to-date safeguarding policy in place.

Where people needed to be deprived of their liberty to keep them safe, the service ensured a deprivation of liberty safeguard (DoLS) was applied for through the relevant local authority.

The service 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.

Although improvements had been made to managing people’s risks, further improvements were required to ensure people’s care plans and risk assessments always contained up-to-date and effective information.

For example, where people had risks in relation to constipation or nutrition, their care plans did not always guide staff how to identify symptoms or when to escalate concerns. Where 1 person required as and when medication to manage their health risk, their care plan did not guide staff about when this should be given. However, we found no evidence this lack of guidance impacted on people’s health outcomes.

Where 1 person had had a recent fall, their falls risk assessment had not been updated. Where another person had had a recent fall, actions had been taken to reduce their risks and their falls risk assessment had been updated, however these changes had not been updated in their mobility care plan.

When the inspection team informed the service about concerns with the information included in care plans, they sent us updated care plans and risk assessments which included enough detail about people’s risks and how staff should support them and escalate concerns.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service had made improvements to the care home environment to ensure it was safe. For example, they had replaced window restrictors to ensure they complied with health and safety legislation, secured tall furniture to bedroom walls and ensured fire exits were clear from obstructions. Storage items had been removed from the laundry room to ensure it could be cleaned effectively.

PAT testing had taken place, and applicable items had been appropriately labelled. Although PAT testing records could be accessed on the PAT testing device, we discussed with maintenance staff the need to have these readily available so that these could be audited more effectively.

An environment checklist had been put in place to ensure any safety concerns could be addressed in a timely way. When we discussed with the registered manager the need to ensure maintenance logs evidenced when actions had been completed, they put a plan in place straight away.

Risk assessments of the environment had been updated where required.

The service had responded effectively to a recent leak in the building, ensuring the affected areas were safe, remedial work was carried out and that people’s care was able to be delivered without disruption.

The service always made sure there were enough qualified, skilled and experienced staff available. However, they did not always make sure staff received effective support, supervision and development.

Although staff now had regular one to one meetings with a senior member of staff, some supervision records lacked information about what was discussed about staff wellbeing, their training needs and about how people were supported. This meant there was a risk the management team would not identify issues with staff or people’s care.

Although improvements had been made to safer recruitment processes, further improvements were required around the quality of references received, management of health declarations and to ensure all DBS (Disclosure and Barring Service) information was available in staff files.

There were enough staff on duty to meet people's needs. The service used a dependency tool to calculate the numbers of staff they needed.

People told us there were enough staff and they felt safe. One person told us, “I’m very safe here and the staff come when I need them.” One relative told us, “I see plenty of staff about and I am sure [person] is safe with them. I can go away and not worry that they will be alright.”

Staff received suitable training to carry out their roles. The registered manager told us they would seek further training for staff about managing people’s skin needs.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Procedures in place to manage the risk of infection were effective. Infection control and prevention checks were carried out regularly and issues were dealt with where required. One professional visiting the service told us, “The [registered manager] is very proactive and engaging and [the service] is quick to let us know about illnesses and infection outbreaks.”

Housekeeping staff were available, and the service was observed to be clean and tidy throughout. One relative told us, “It’s always clean and tidy here.” One staff member told us, “We try to keep everything clean and tidy. We have designated domestic staff who just do cleaning. Night staff clean the lounges too.”

Staff were provided with personal protective equipment (PPE) and were observed wearing and removing this appropriately.

Safe infection prevention and control practice information was displayed throughout the care home. An up-to-date infection prevention and control policy was in place.

When we discussed with the registered manager issues regarding a cleaning trolley being left unattended and a clinical waste bin being left open, these were addressed straight away. The registered manager told us they were reviewing laundry drying procedures to minimise the risk of spreading infection.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The service was now recording in more detail the use of topical medicines and had introduced body maps to indicate where topical creams were being applied. Risk assessments were now in place in relation to the flammability of emollients. However, we found where topical creams were stored in people’s rooms, this was not always risk assessed, and some did not contain ‘opened’ dates on their labels. This meant the service could not be assured these medicines were always safe and effective. When we discussed this with the registered manager, these creams were removed straight away.

Where people required their drinks to be thickened, staff did not always record the level of thickener added to drinks.

Care plans did not always include information about how medicines should be administered. For example, where one person required medicines to be given covertly, their care plan did not guide staff how to do this.

Although the service had begun to carry out audits of administration, storage and disposal of medicines, further improvements were needed to ensure these were carried out consistently and effectively.

There was an up-to-date medicines policy in place.