Rosedene 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 good. 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 governance at the service.

This service scored 62 (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 provider promoted a vision for the service which leaders and staff embraced. This gave the whole staff team a unified purpose. Staff told us they were happy in their work. One member of staff told us, “I love what we do here. I like the challenge.” Another member of staff said, “I have the autonomy I need. I feel supported. I don’t want to take issues home and I don’t because I’m supported.”

New staff were given a handbook which explained the provider’s mission and purpose. This was reinforced during induction. Additionally, the provider ran a ‘Values workshop’ where staff discussed ‘what would service users family say about you?’ ‘Why do you come to work?’ And ‘what makes you proud of what you do?’ This meant the provider’s vision for the service was clear and understood.

The registered manager shared the compliments and thank you cards received by the service with the team. This was used to boost morale and role model good practice. One member of staff described this as, “motivating.”

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.

Healthcare professionals and staff spoke positively about the leadership of the service. One healthcare professional told us, “I think the home is well led.” A member of staff told us, “The home is well run. If we have concerns, the leaders say their door is always open.” Another member of staff said, “The leaders are supportive.”

The leadership team were well established in their roles and had been in post for many years. Care staff were supported to progress their careers through training and promotion and nurses were supported to maintain the skills and knowledge requirements of their regulatory body.

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

Staff told us they felt comfortable sharing their views. One member of staff told us, “[Leaders] take on board our ideas. Over the years the staff have become more confident. This is healthy for the team.” Staff were able to share their views at team meetings, supervision meetings, handover meetings and informally at any time with leaders. The provider had a whistle-blowing policy. This meant that staff knew the actions they should take if their concerns about people’s safety and wellbeing were not addressed by leaders.

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.

People receiving care and support came from a wide range of backgrounds and were supported by a diverse workforce. One member of staff told us, “Staff come from different walks of life. We get on well. I have never noticed discrimination.” Staff received training in equality and diversity. This meant staff had an understanding about discrimination and anti-discriminatory practice.

The staff team was well established with many staff having worked in the service for years, and in some cases decades. One healthcare professional told us, “There is stable workforce. It is well led.” Staff expressed the desire to meet people’s needs to the best of their ability. One member of staff told us, “There are challenges here, but we meet them.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The quality of care and support people received was monitored by the provider through a range of audits. For example, leaders carried out checks of staff training and care records. However, audits did not always identify shortfalls. For example, medicines audits did not identify shortfalls around covert medicines management, and safety audits failed to identify that fire alarm and emergency lighting systems had not been tested for months. Additionally, when audits identified shortfalls, timely action was not always undertaken to address them. For example, a health and safety audit 6 months before our inspection identified a hole in a carpet. Whilst the hole had been taped over to prevent tripping, the carpet was not replaced. This meant that audits did not always lead to improvements to the service people received.

The provider maintained records of people’s care and support. One healthcare professional told us, “Record keeping in the service is good.” Leaders met daily to discuss people’s changing needs and workaround checks were undertaken. People, relatives and visitors knew the leaders and found them accessible. One healthcare professional told us, “The Manager is always visible and is welcoming and happy to deal with any concerns raised. I think the home is well led.”

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 worked in partnership with other organisations to meet people’s needs. Referrals were made to a range of healthcare services and professionals. These included mental health practitioners, behavioural and communication support specialists, tissue viability nursing and speech and language therapists. This meant that Rosedene Nursing Home’s staff and nurses worked collaboratively with healthcare professionals.

Staff enabled people to access resources in their local community to meet people’s needs. These included supporting people’s spirituality by facilitating visits to and from local faith institutions. People were also supported to avail of local amenities such as parks and cafes.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider worked towards improving the service. The service evolved its care records for people from paper-based files to electronic care records. This improved ease of oversight and enabled individual and group themes and trends to be more readily identified. All staff were trained to use the system and leaders carried out audits of it.

The provider sought knowledge from others to improve people’s care and support. The registered manager attended the local authority’s provider’s forum, where best practice guidance was shared. The provider also sought to learn from partner services. One Healthcare professional told us, “The nursing team are aware of their limitations and know when to ask for support.” This meant the provider sought assistance and expertise to meet gaps in knowledge.