Rosecroft Residential 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 good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was in breach of legal regulation in relation to safe care and treatment. The provider did not always ensure the risks in the home environment were identified and acted on. Medicines were not always managed safely.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff knew how to report safety incidents which were investigated by the management team and immediate actions were taken where required. One staff member told us, “Incidents are reported to management, and they are investigated.” Another staff member told us, “Incidents are handled correctly and [registered manager] feeds back.”

The service analysed data from safety events, such as falls, and carried out regular audits of incidents. Learning from incidents was shared in staff meetings and one-to-one meetings with staff.

The service did not always make sure there was continuity of care, including when people moved between different services.

People had hospital passports. However, these did not always include enough information about people’s needs and care plans did not consistently include up-to-date information regarding people’s current needs and risks. This meant there was a risk people would not receive seamless care delivery should they be referred into another service or go to hospital.

The service 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.

Staff had received safeguarding training and knew how to identify and report abuse. One staff member told us, “I have experience in reporting safeguarding concerns and know when to raise issues.”

The service investigated safeguarding incidents and shared concerns quickly with the relevant authorities. We discussed with the registered manager how they could evidence the decision making around safeguarding referrals.

There was an up-to-date safeguarding policy.

Where people needed to be deprived of their liberty to keep them safe, the service ensured a deprivation of liberty safeguard (DoLS) was applied for through the relevant local authority.

We identified out of date contact information for safeguarding authorities, kept at the entrance of the care home. When the inspection team informed the registered manager about this, they updated this information straight away.

The service did not always work well with people to understand and manage risks.

People’s risks were not always recorded effectively in their care plans or risk assessments. For example, we found where people had specific risks around medication, skin integrity or swallowing, sufficient information was not always available to guide staff how to manage these effectively. This meant risks to people may not have been managed consistently.

However, we observed staff supporting people safely in relation to mobility and eating and drinking. We also received positive feedback from relatives and visiting professionals about how people’s risks were managed. One relative told us, “[Person] is helped with hoisting and incontinence. There’s always been staff there to help.” One professional told us, “People’s mobility needs are well cared for.”

The service did not always detect and control potential risks in the care environment.

The provider had identified defects with fire doors however these had either not been repaired effectively or in a timely way.

The provider carried out routine safety checks of the premises but these checks had not identified issues with flammable items being stored in electrics cupboards. During our inspection, we found these cupboards had not been locked, meaning there was an increased risk in relation to fire and people suffering from an electrical shock.

We identified multiple radiators throughout the care home were not covered and there was copper piping exposed under several sinks, leaving people at risk of scalds.

The provider had not been consistently recording water temperatures as part of legionella procedures. This meant people were at increased risk from legionella.

When the inspection team informed the provider about these concerns, they put a plan in place straight away to ensure issues with fire doors were remedied as soon as practicable. Items were removed from electrics cupboards which were then locked. Immediate action was taken to cover some radiators and pipes, and an action plan was put in place to address the others. They put a plan in place to ensure water temperatures were recorded in line with policy.

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.

There were enough staff on duty to meet people's needs. The provider used a dependency tool to calculate the numbers of staff they needed. One relative told us, “There are plenty of staff on and carers are good with [person].”

Staff felt they delivered safe care and had received the training required to undertake their roles safely. One staff member told us, “When I started, I had an induction and did all my training. I shadowed experienced staff and felt ready to work on the floor.”

Team meetings, one-to-one meetings and daily handovers were in place to support staff to provide safe care to people.

Safe recruitment procedures had been followed generally, but we discussed with the registered manager the need to ensure gaps in employment histories were always fully explained.

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

The care home was clean and tidy. One relative told us, “The care home is clean and well maintained and they always seem to be trying to improve it.”

Staff were provided with personal protective equipment (PPE) and were observed wearing and removing this appropriately. One staff member told us, “We have plenty of gloves, aprons and other PPE. We know how to use and dispose of PPE.”

There were handwashing facilities throughout the building and also access to hand gel. There were clear instructions above every sink on how to wash hands properly.

Staff had received training to support with minimising the risk of infection, and information about safe infection prevention and control practices was displayed throughout the care home.

There was an up-to-date infection prevention and control policy.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

One person had their medicines reviewed by a GP who recommended stopping a medication prescribed to prevent and treat constipation, but staff had continued to give the medication without further instruction.

One person was prescribed a flammable cream, however there was no risk assessment around the increased fire risk. Staff were not completing body maps for its application and there was no guidance for staff about where to apply the cream.

Another person’s creams, did not contain ‘opened’ or ‘use by’ labels, and where they did have labels, some instructions of use had faded and were not legible. This meant creams may have been ineffective or applied incorrectly.

One person was given ‘as required’ medication however there was no protocol to guide staff about when it was needed, or how to administer it safely.

Medicines room temperature records indicated the room was not always at a safe temperature. The process staff followed to record the temperature was not effective and there was no guidance available for staff about safe room temperature ranges. When the inspection team informed the provider about these concerns, they purchased a new thermometer and displayed guidance for staff to follow.

There was an up-to-date medicines policy.