Rose Belle

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 provider was in breach of legal regulation in relation to good governance.

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.

There was a consistent management and staff team at Rose Belle and staff told us they felt supported to raise any concerns to management. Feedback from staff was positive about working at Rose Belle and were passionate about the people they cared for. One staff member told us, “The management takes a proactive interest in both the welfare of the residents and the professional development of the staff.”

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.

While the registered manager was present at Rose Belle, systems and processes were not effective and robust enough to identify, address and mitigate all risks within the service. This meant the lack of effective oversight did not ensure good governance and regulatory compliance. People, their relatives and staff we spoke with were positive about the management at Rose Belle.

The provider acknowledged where improvements were needed, particularly around the consistency of peoples care plans, and had started to address this at the time of inspection, however this still required further work to become embedded. They were responsive, open and honest throughout the assessment and responded positively to feedback given.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had a speaking up and whistle blowing policy in place. Staff had received supervisions and told us they felt supported by management and felt comfortable with raising any concerns. Comments included, “Management are responsive and supportive” and “I feel [registered manager] is a good manager and supports me.”

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 service supported a diverse workforce, and there was no evidence that staff felt disadvantaged or unsupported.

During our onsite inspection, we observe a positive culture and feedback from staff was positive about being treated fairly at work. One staff member told us, “I feel confident that I can raise concerns or make complaint. I know that any issues I bring up will be taken seriously without fear of reprisal.”

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.

There was no evidence of recording or reporting of accidents and incidents. The provider had not been submitting statutory notifications to CQC in line with their regulatory requirements.

The provider had some processes in place to monitor the quality of the service and had recently implemented some new audits; however, these were not always effective. For example, IPC concerns around the communal bathrooms.

We identified that care plans and risk assessments were not always up to date and it was not clear when they had been reviewed. One person had not had a referral to the SALT team, which placed them at potential risk, however the provider has since completed this referral.

Despite staff informing us that they received regular training, the training matrix did identify gaps in staff training. The provider had been working to address these gaps, but we could not be assured staff had all the appropriate knowledge available to them to safely support people.

The provider acted quickly on areas of concern and feedback we provided and were also being supported by the local authority to help drive improvement of the service.

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.

Staff recognised the importance of maintaining close connections with external healthcare professionals and for people to maintain access to the local community. People were supported to access the community as they wished, including visiting family and attending college.

External healthcare professionals we spoke with did not raise any concerns about the service or the way they collaborated with them.

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.

Systems were not effective in consistently ensuring ongoing learning and improvement. For example, there was no evidence of recording of accidents and incidents, therefore the provider was not able to evidence any actions taken and lessons learned from accidents or incidents. Audits had not been effective in identifying the issues we found. This meant it was not always clear how the provider consistently drove improvement, identified concerns and how they learned from these. We found no evidence people had been harmed. The provider acknowledged that improvements were needed and was in the process of starting to implement these improvements to make sure people always received high quality care and support.