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 requires improvement. At this assessment the rating has remained 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 governance at the service.

This service scored 61 (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 a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The registered manager worked closely with all staff to embed the provider’s values and drive continued improvement. People, relatives and staff spoke positively about the registered manager’s proactive approach and the improvements made at the service. Comments included, "Since the last assessment, I have noticed significant improvements. The gates are now kept secure, people are making much greater use of the garden, and there always seems to be more staff present in the lounge areas" and "Since the beginning of the year, there has been a huge improvement across the service, and as a family we are extremely happy with the care and support (person's name) receives.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The provider continued to work with an external care consultancy to support improvements following the last assessment. We found evidence that identified shortfalls were being addressed and that oversight of improvement plans had strengthened. For example, regular audits were taking place.

People, their relatives, and other stakeholders all provided positive feedback about the improvements made since the Registered Manager joined the service. Comments included, "The registered manager, is highly visible within the service and regularly keeps me updated on what (person's name) has been doing" and "The registered manager has really made a big difference here. Nothing is too much trouble, and they are very responsive when I speak with them."

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

Systems remained in place to enable people, relatives, and staff to provide feedback. However; it was still not always clear what action the management team had taken in response to the feedback received. We identified this at the last assessment and no action had been taken to address this.

The provider valued and supported their workforce, there were opportunities to further enhance diversity, equality, and equity and strengthen an inclusive culture across the service.

At the previous assessment, the registered manager advised that staff initiatives were being considered to further improve workplace culture and promote staff wellbeing. However, during this assessment, we did not see any evidence that these initiatives had been implemented.

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.

Leaders did not consistently use the best available information about risk, performance and outcomes to drive improvement, and information was not always shared securely or appropriately with others when required.

Governance arrangements were still being embedded in practice. However, actions identified through audits were not consistently followed up or completed within expected timescales. As a result, opportunities to drive and sustain improvement were not consistently maximised.

Audits were not always correct. When actions were identified during audits, they were not always dealt with, and some of the same issues continued to appear in later monthly audits without any evidence that they had been resolved.

The provider had a governance tracker in place to record any identified actions from audits. However, we found actions identified in audits were not always recorded on this tracker.

Improvements were needed in care records to ensure information about people's needs was accurate, up to date, and clearly documented to show people received consistent care.

Quality assurance systems were becoming a regular part of how the service monitored and improved the quality of care. The management team completed weekly and monthly audits, with monthly oversight and review provided by a consultant working with the provider.

The registered manager was open and honest about the service's improvement journey. They recognise the progress that had been made and were clear about the areas that still required improving upon. The registered manager highlighted areas where ongoing support was needed to support their own continued professional development.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider continued to improve the oversight of planned care delivery. Regular care plan reviews took place with people and their relatives. A relative told us they were fully involved in this process, "They actively involve us in discussions about her care and regularly seek our input into (Person's name) care plan, which I have seen and reviewed."

Stakeholders also provided positive feedback about the improvements they had noted to improve 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 always implemented effectively to enable continuous learning from accidents and incidents.