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 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.

This service scored 50 (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 had clear goals and plans in place to make improvements at the service, as identified at the last assessment.

The service no longer provided nursing care, and the staffing structure had been revised to reflect this change. Some staff felt that further improvements were still needed to ensure everyone consistently followed the provider’s values and expected ways of working.

The manager was working with staff to promote the providers values and further improve the culture of the service. People, relatives and staff felt that the manager was working in a more proactive way and supporting the improvements needed. One staff member told us, "I do think the new manager has brought in more teamwork and they identify issues which is then shared with the whole staff team."

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The provider was working with an external care consultancy to support the service make improvements identified at the last assessment. However, there was limited evidence to show the provider was proactively addressing identified shortfalls in a timely manner. For example, at the last assessment we identified that the carpet in the communal areas presented an offensive odour. This remained at this assessment and whilst the provider had recorded this on a maintenance plan there was no clear timescale recorded to show when this would be completed.

The manager was supported by the external care consultancy who had provided a suite of governance audits to improve the oversight at the service. However, these audits were not always fully completed or did not reflect the actions required to make the identified improvements. This had not been identified by the provider.

The provider did not always foster a positive culture where people felt they could speak up and their voice would be heard.

At the last assessment people were not provided opportunities to speak up about the care they received. At this assessment we found that systems were now in place to allow people, relatives and staff to provide feedback. However, it was not always clear what action had been taken by the management team when this feedback had been received.

The provider 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 provider employed a diverse workforce and promoted workforce equality and staff felt they were treated with respect. Staff told us they had been supported well when dealing with private concerns outside of their employment.

The manager told us they were considering implementing staff initiatives to further enhance workplace culture and support staff wellbeing.

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 the last assessment, the provider did not have effective oversight of the service. Although some progress had been made, further improvements were required to ensure oversight was robust, embedded, and sustained.

A new audit structure had been introduced; however, audits were not always completed in line with the framework, were sometimes left incomplete, and did not consistently identify the actions required to drive improvement.

Action plans lacked sufficient detail about what actions were required and the timescales for completing them. They did not always correspond with audit findings, and several actions had passed their stated deadlines without review or completion. There was little recorded evidence to demonstrate how identified actions were monitored, reviewed, or completed.

People’s care records were missing essential information and did not provide adequate guidance to support safe and consistent care. The manager told us they were in the process of reviewing all care records to ensure they accurately reflected people’s current needs.

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.

The service worked with external professionals when required. However, records did not always reflect professional advice given or actions taken to promote partnership working.

The provider 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 provider’s quality assurance processes were not implemented effectively and did not identify the shortfalls found during this assessment, some of which had also been noted at the previous assessment. However, the manager had recently implemented reflective practice reviews to support further improvement of the service. These were shared with the staff team to encourage learning and promote service-wide development.