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 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.

The service was in breach of legal regulations in relation to safe care and treatment and safe recruitment.

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 provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider’s policy lacked sufficient detail regarding the required staff response to accidents and incidents. Although staff routinely documented accidents in people's daily notes, key information was often omitted. Systems to support the reviewing of accidents were in place; however, the quality and consistency of the information recorded did not fully support robust oversight.

The provider and new manager were working together to identify further areas for improvement, enhance oversight arrangements, and embed safer working practices across the service. The new manager is actively working to develop a more open culture and is promoting the use of reflective practice to support learning and improvement.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People received continuity of care. Staff reviewed assessment information before admission and used hospital passports, which supported people during hospital visits or when attending appointments.

Staff demonstrated understanding of people they supported and their individual health needs. They were able to identify changes in wellbeing promptly and responded appropriately. When people were admitted to hospital, staff continued to offer support beyond their normal duties. For example, one staff member visited a person on their day off to provide nail care.

The provider had systems and processes in place for recording safeguarding concerns, and staff reported that they received training to help them understand how to keep people safe. These foundations offered a basis on which to build stronger safeguarding practice.

The management team followed internal and external processes to keep people safe. Staff demonstrated a good understanding of how to keep people safe and the action to take to protect from harm and abuse.

People told us that they felt safe at the service comments included, "They [staff] know what they are doing, it is safe and they are always happy to support me, however I want it" and "I think its bloody fantastic I wouldn’t go anywhere else."

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the Mental capacity Act, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. All legal applications had been made in accordance with Deprivation of Liberty Safeguards (DoLS). This meant people’s rights were fully respected. The manager kept a record of DoLS applications and authorisations, which were regularly reviewed to make sure authorisations were current.

The provider 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.

Risks to people were not clearly identified or recorded within care plans. Care plans lacked details of the control measures staff should follow to keep people safe. People's individual risk assessments were unclear and not person‑centred. These records were not consistently monitored, reviewed, or updated when people's needs changed.

Staff did not always monitor clinical risk effectively. Monitoring charts such as fluid charts and repositioning charts were not routinely checked to explore any shortfalls, so concerns could be picked up quickly and escalated if required.

The management team were in the process of reviewing people’s care plans and planned to introduce a new system to ensure these were reviewed monthly.

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 consistently failed to identify and address potential environmental risks. For example, fire doors were not compliant with fire safety requirements, and infection control measures were not effectively promoted throughout the service.

An action plan had been developed, to address some of the concerns relating to the environment, equipment and furnishings, however, there were no definitive timescales for when the required improvements would be completed.

The provider had addressed risks relating to window safety identified at our previous assessment.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

The provider had reviewed recruitment processes since the last assessment where shortfalls were identified. However, during this assessment, safe recruitment procedures continue to require improvement to ensure all mandatory pre‑employment checks were consistently obtained and recorded. For example, staff files did not contain proof of identification.

External contractors working within the service to provide activities to people were not consistently vetted to confirm they were safe to work with vulnerable people. We observed people receiving support from these staff with moving and handling and hand washing during our assessment. There was no evidence to show these staff had completed appropriate training to provide this additional support.

New staff completed an induction; however, some felt the process could be strengthened. For example, they suggested having additional shadowing shifts and more in‑depth training on specific health conditions. Staff told us they felt supported by the management team and reported receiving appropriate training for their roles.

People, staff and their relatives felt staffing levels at the service were appropriate. People told us, "Staff availability is much better with the walkie talkies, very efficient" and "There is always someone around if you need help."

Staff told us, "The staffing levels are the best I have seen, sometimes we are short due to sickness, but the management team do try and cover as best they can" and "Staffing levels have improved, it depends on the day, some days are busy but all in all they have improved. We don’t feel like we are tearing our hair out anymore."

Relatives told us, "I have noticed recently there seems to be more staff" and "I think there is enough staff.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Areas of the environment continued to present an offensive odour. This was noted at our last assessment. Equipment and furnishings at the service were not adequately maintained and did not support effective cleaning and infection prevention.

Personal protective equipment (PPE) was not stored appropriately and remained exposed to contamination risks.

Staff did not demonstrate safe infection prevention and control practices. For example, we observed one staff member removing PPE in a communal area and, on 4 separate occasions staff had disposed of used PPE in communal bins with no lids on them. This was fed back to the management team who removed the bin out of the communal area.

Infection control and environmental audits were in place and had identified some of the same issues we found during this assessment. However, no action had been taken to address these concerns.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicines as prescribed. The service had systems in place to ensure the safe management and administration of medicines. Individual fire risk assessments were completed for people using paraffin‑based skin products. Stock checks were accurate, and clear instructions were available for medicines that required administration at specific times.

Staff also had access to detailed, person‑specific guidance for administering “PRN” (as‑required) medicines. Where residents required medicines via a PEG tube, appropriate guidance was in place to support trained staff to administer these safely. Topical creams and ointments were recorded on Medicines Administration Records (MARs), supported by body maps to show correct application sites. An effective process was in place to administer medicines via patches.

Medicines were stored safely, with temperature monitoring completed in line with national guidance. Handwritten MARs were double‑signed to confirm accuracy. Controlled drugs were managed appropriately, with regular balance checks carried out according to national standards.

Processes were in place to report and record any medicines‑related incidents or errors. Staff received medicines management training and induction, and their competencies were regularly assessed. Managers and trained staff also completed regular audits to ensure procedures were followed consistently.