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 inadequate. 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.

The service was in breach of legal regulation in relation to good governance as the systems in place to assess and manage the quality and safety of the service were not always effective.

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 service did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

Although staff understood the needs of people and their communities, systems in place to ensure people and staff were involved in the running of the service and making improvements, were not always effective.

Staff could not always readily explain what the vision and values of the service were as these had not been fully developed and shared with staff.

Although leaders were passionate about delivering good care and were compassionate in how they supported people and their staff, systems in place to promote the culture and values of the service required improvements.

Throughout the course of the inspection, the management team acted with integrity, openness and honesty. The registered manager acknowledged although action had been taken to improve the safety and governance of the service, further improvements were needed to ensure governance processes were used consistently and effectively.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service had a whistleblowing policy which staff understood. Staff were able to report concerns to the registered manager who had an open-door policy.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The registered manager told us, “We try to accommodate the needs of our staff where things may affect their ability to work. This includes reviewing rotas and reducing hours where needed.”

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

Governance systems in place to ensure lessons could be learned from safety and safeguarding incidents were not always effective.

Audits of care plans had not been taking place which meant the service could not always identify when care plans and risk assessments had not been updated following changes in needs and risks or when care plans contained inconsistent or out-of-date information.

Systems in place to monitor staff wellbeing issues or additional training needs were not always effective as records were not always completed satisfactorily.

Further improvements were required to safer recruitment audits to ensure issues with staff records could be identified and acted on in a timely way.

Governance systems in place to ensure medicines were managed safely had been improved however audits had still not been carried out consistently and effectively. This meant issues with the storage and labelling of topical creams, guidance around covert medications and with recording people’s thickeners had not been identified and acted on prior to our inspection.

Further improvements were required to auditing people’s consent and mental capacity records to ensure issues could be identified and acted on in a timely way.

Governance systems in place to ensure people, their relatives and staff could give feedback about quality care were not always effective.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

The service was embedded in the community it served and was considered a valued partner by others in the community.One professional visiting the service told us, “In my opinion, this is one of the better homes in the area.”

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

The service was engaging in a quality improvement process with the local authority and health partners. Although this had led to some improvements in the delivery of safe care, support was still required to ensure governance systems were used consistently and effectively and to develop a focus on continuous learning.

The registered manager attended manager forums in the local network.