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 good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 was continuing to develop a proactive and positive safety culture based on openness and honesty. The provider had a clear policy in place for staff to follow in the event of an accident or incident. While staff generally supported safety practices, there were some occasions where safety concerns were not fully acted upon, and learning from incidents was not always consistently used to inform and embed good practice.

Staff did not consistently fill in accident and incident forms fully, which meant important information was sometimes missing.

The provider had systems in place to monitor and review accidents and incidents. However, the information held within these systems did not always match the records that had been completed. In addition, there was limited evidence of any follow-up actions being taken, lessons being learned, or changes being made to reduce the risk of similar incidents happening again.

The provider did not always clearly demonstrate that accidents and incidents were being effectively reviewed and used to improve safety.

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 continued to receive consistent care that met their needs. Before people moved into the service, the management team carefully reviewed information about their care and support needs. Care plans were regularly updated and included more detailed information, helping staff understand how to support each person effectively.

These improved care plans helped staff to notice and respond quickly to any changes in people’s health and wellbeing. When concerns arose, staff acted promptly and arranged support from the appropriate healthcare professionals and services to make sure people received the care they needed. For example, referrals to falls team and district nursing team.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People and their relatives felt the service was safe. One person told us, "I'm very safe here, it’s a nice place. A relative told us, "(Person's name) is safe, well cared for, and supported by an incredible team of compassionate and dedicated staff.

The management team continued to follow internal and external processes to keep people safe.

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 worked with people to understand and manage risks by thinking holistically. 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.

Monitoring systems were not always effective in identifying when people were not receiving care as set out in their care plans and risk assessments. For example, one person who needed regular repositioning to reduce the risk of pressure sores was not consistently repositioned as often as specified in their care plan. We discussed this with the management team, who told us they would take action to strengthen oversight of monitoring records and improve staff compliance with care plans.

Care plans and risk assessments had been reviewed and updated so that risks to people were clearly identified, with detailed guidance for staff on the steps they should take to keep people safe. Quality assurance processes had also increased the frequency of care plan reviews. While improvements had been made, further work was needed to ensure monitoring systems consistently identified when care was not delivered in line with people's assessed needs.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The environment had significantly improved, and the service presented a warm and welcoming feeling. Environmental risks were reviewed and appropriate control measures were implemented to ensure the safety of people using the service.

Fire safety issues, including non-compliant fire doors, were rectified, and infection prevention and control measures were strengthened and embedded throughout the service.

Equipment, facilities and furnishings were also reviewed and upgraded where needed. The provider closely monitored improvement plans in relation to the environment and ensured clear deadlines were in place to ensure all necessary changes were completed successfully.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider had taken action to strengthen recruitment processes following concerns identified at the previous assessment. Improvements included increased oversight of recruitment records and a review of pre-employment checks for all staff, including external contractors working within the service.

Newly recruited staff had the appropriate checks in place before starting work. Staff told us they completed an induction programme and spoke positively about the support they received when joining the service and settling into their roles.

People, staff and relatives consistently told us staffing levels had improved and were sufficient to meet people's needs. People said, "There is always plenty of staff around and they keep us well informed about what's happening during the day", "If I need them (staff) they are here" and "There is definitely more staff around these days"

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Since the previous assessment, the service had made significant improvements in infection prevention and control and environmental standards. The offensive odour identified during the previous assessments was no longer present, and the environment was observed to be clean, well maintained and supportive of effective infection prevention practices.

Equipment and furnishings had been appropriately maintained and supported effective cleaning. Personal protective equipment (PPE) was stored safely and protected from contamination risks. Staff demonstrated improved infection prevention and control practices, including the appropriate use, removal and disposal of PPE.

Auditing processes to support infection control were used more effectively, and issues identified through audits were addressed in a timely manner.

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.

Medicines continued to be handled safely, with reliable systems in place for storing, administering and monitoring them. Staff had clear instructions to help them give medicines correctly, including medicines that need to be given at specific times, medicines taken only when needed, medicines given through feeding tubes (PEG), creams and medicated patches.

Medicines were stored securely, and storage temperatures were checked regularly in line with national guidance to ensure medicines remained safe and effective. Controlled drugs were managed appropriately, with routine checks carried out to confirm stocks were accurate.

There were effective processes for reporting and learning from any medicine-related incidents. Staff received regular training in medicines management and had their skills assessed to ensure they remained competent. Managers and trained staff also carried out regular audits and monitoring checks to help maintain high standards and support safe practice.