Rose Villa Nursing 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 requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of legal regulation in relation to people’s safe care and treatment, safeguarding and staffing.

This service scored 34 (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.

Serious risks to people’s safety and wellbeing were identified at the previous assessment. The provider had taken no action, which exposed people to continued safety risks. Systems and processes were not in place to support the service to learn from incidents. We found evidence of people sustaining injuries which were not recorded within the accident and incident record. The management did not keep detailed records of all accidents and incidents which meant they were unable to identify lessons learnt and improvements to prevent reoccurrences.

The provider 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. People's health needs were not clearly documented, and associated risks were not always considered. People's records did not contain up to date information regarding their care and support. Hospital passports were in place, however these lacked important information regarding people’s safety, health and wellbeing.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not 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 share concerns quickly and appropriately. Systems and processes were in place to record any safeguarding concerns. However, during the assessment we made 8 referrals to the local safeguarding team due to concerns relating to the care and support people received at the service.

Staff told us they completed safeguarding training. However, some staff did not have a full awareness about the action to take to ensure people were safe from harm.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The provider failed to identify, assess and act on risks to people to keep them safefrom the risk of harm. For example, People on anti-coagulants medicines did not have appropriate risk assessments in place. This posed a risk of excessive bleeding if they were to be injured or if they had a fall. The provider had not always assessed and managed risks relating to people's specific health conditions. Care plans did not contain information regarding potential risks relating to people's health needs and how to mitigate these. For example, one person who had 2 long standing health conditions had no care plan or risk assessment in place to guide staff how to monitor symptoms of either condition. One relative told us, “[Persons name] was getting up at home and getting into the wheelchair, but they have gone back a step and is staying bed most of the time now.”

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. The provider failed to address health and safety concerns in the building. Risks in relation to window safety which had been identified at our last inspection had not been actioned or addressed and continued to be a potential risk to people’s safety. The provider took some action after our assessment to put systems in place to address these concerns. We identified that out of 40 staff only 16 had completed fire safety training. Only 1 member of the night staff had completed fire safety training. This put people at risk of been supported by staff who were not appropriately trained. The provider did not have a process in place for staff signing into and out of the service. This posed a fire safety risk as there was no recorded information of staff that were in the building. People’s Personal Emergency Evacuation Plans did not always contain sufficient information to ensure they would be supported appropriately in the event of an emergency.

The provider did not 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 work together well to provide safe care that met people’s individual needs. Staff were rushed and did not have time to spend with people or attend to their needs. People spent long periods of time sat in communal areas, often without staff present. One person did not receive the support they needed to access baths or showers. We observed people waiting for support including drinks, meals and personal care. Staff told us they did not feel there was enough staff to support people's needs. Comments included, "Staffing is not great we are really busy all the time" and "Staffing levels are shocking but no one seems to care about that. I would love to be able to spend time with people and ask them about their day but we are not able to." Some staff expressed frustrations regarding the staff morale and support they received from management. Relatives did not always feel there was enough staff. Comments included, “The manager says they have enough, but it seems a bit tight and doesn’t cope if holidays, sickness or an emergency” and “No, I don’t think there is enough staff. I brought this up with a couple of seniors. The stafflook tired and overworked.” The provider carried out appropriate recruitment checks to ensure only suitable people were employed at the service.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. The provider did not properly maintain the premises to ensure effective cleaning and infection prevention. Areas of the service had an offensive smell. We identified noticeable damage within one person's room and staff told us it had been like it for a long time. The provider’s training matrix showed only 3 staff had completed infection control training in 2024 and only 2 staff in 2025. Personal protective equipment was not stored appropriately and was exposed to the risk of cross contamination.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. People's medicines were not managed safely. People did not receive their medicines as prescribed. For example, we observed staff administering medicines to people who required time specific medicines to be given 30 to 60 minutes before food. These medicines were given alongside their breakfast. Best practice guidance was not followed in relation to the safe management of medicine. Documentation to support the safe administration of medicines was not in place or accurately completed. Stock checks completed and during the assessment identified discrepancies with stock amounts for some medicines. This meant we could not be assured that people had received their medicines. Regular audits of people's medicines were completed. However, these audits had failed to identify the concerns we found during the assessment.