Rose Villa Nursing Home

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 remained 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 provider was in breach of legal regulation in relation to the governance of the service.

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. They did not understand the challenges and the needs of people and their communities. The service did not foster a positive culture for people. The providers values were not upheld by the management team and staff morale was low. There was a clear lack of leadership and oversight of the service which impacted directly on care provided to people.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty. The manager did not demonstrate an understanding of their responsibilities in providing safe and effective care. The manager did not recognise the inconsistencies we identified in how risks to people were being managed. They did not respond appropriately to prevent the recurrence of adverse events, including medication errors, and they had not acted when alerted to poor practices regarding medicines. Systems and processes were not operated effectively to ensure the service was assessed or monitored for quality and safety in line with requirements. This led to breaches of regulation.

People did not always feel they could speak up and that their voice would be heard. The provider did not provide regular opportunities to provide feedback about the running of the service. Staff did not feel they could always approach the management team with issues as they were not confident these would be responded to appropriately. One staff member told us, "They [management] come and go as they please never really see them much on a night unless they stay for handover but that is not very often.”

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. Staff did not receive regular opportunities to provide feedback about the service. Staff meetings were not always utilised as an opportunity for staff to feedback about their ideas or concerns at the service.

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. At our last inspection the provider failed to ensure there were effective governance systems to assess, monitor and drive improvement in the quality and safety of the service. At this assessment we found little improvements had been made and people continued to reside in a service where widespread and significant shortfalls remained. The provider failed to embed effective governance to assess, monitor and drive improvement in the quality and safety of the services provided. Issues relating to staffing, risks to people, environmental safety and person-centred care had not been identified or addressed. Records failed to identify the care people required or received. Care plans did not contain detailed information regarding people's health needs. Important information about people's allergies was not always recorded within appropriate records and monitoring charts were inconsistently completed. For example, there were large gaps in recording for people's pressure area care and daily records were brief and repetitive.

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. External professionals and agencies had ongoing involvement in people's care. However, there was little evidence of partnership working. Where professional health advice had been sought there was minimal evidence staff followed this and shared updates with relevant agencies. We spoke with a visiting healthcare professional who told us, "Some people look well cared for; the people in the lounge look ok, but the people that are in their own rooms could do with more attention."

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. There remained little evidence of learning and service improvement.