Rothsay Grange

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

This service scored 72 (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 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.

People told us they felt safe living at the service and people’s relatives agreed. One person’s relative said, “I have never doubted that [name] is safe there. From the outset, the management, particularly [staff name] have been brilliant.”

Records showed incidents were logged and investigated. If needed, onward referrals to external agencies were made. There was triangulation of incidents, outcomes and analysis. For example, when people had a fall, records showed these were investigated, and care plans were reviewed. If people sustained 3 or more falls, clinical analysis was carried out. The deputy manager described scenarios where people had moved to a different bedroom, or a bed had been moved against a wall. We were told about one person whose eyesight was affected by the lighting, and so improved lighting was put in place, and they had subsequently not fallen.

Effective systems were in place to identify any trends or patterns in accident and incidents so action could be taken to recognise and mitigate any emerging risks. Lessons learnt were discussed at team meetings to aid staff learning and development. Incidents and accidents were also discussed at stand-up meetings. The deputy manager said, “Everyone has some input. It's a whole home approach.”

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.

Records showed the service worked with healthcare partners such as the GP and other members of the multi-disciplinary team. Referrals had been made to external health professionals such as the older people’s mental health team and speech and language therapist (SALT). One professional fed back to us that in their opinion, referrals were made in a timely manner.

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 told us they felt confident people were safe. One person’s relative said, “We do feel that [name] is safe, even though [they] put [themselves] at risk by wandering off on [their] own and falling a few times.”

Staff had received safeguarding training and understood their responsibilities in keeping people safe. A member of staff told us, “Yes, we do this training every year. We do it online as part of e-learning and in person, it’s mentioned during the moving and handling training as well. Safeguarding is putting things in place to protect the person you’re looking after.”

We reviewed records which showed that safeguarding incidents were referred to the local authority and Care Quality Commission appropriately.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments had been carried out and regularly reviewed. When risks to people were identified, care plans provided clear guidance for staff on how to reduce the risks. For example, when people were assessed as being at risk of skin damage, care plans informed staff how often people should be supported to change position, and the signs of skin damage to be aware of. Position change charts we looked at showed people had their positions changed in line with care plan guidance. Staff we spoke with knew which people were at risk of skin damage and knew the how to monitor and protect people’s skin from damage. However, where some people at the service were at risk of seizures, staff knowledge around which people were at risk was inconsistent. Staff knowledge about what to do in the event of someone having a seizure was also inconsistent. We fed this back to the management team on day 2 of the inspection and the following day they told us they had arranged additional training sessions and educational material for staff. Staff supervision tools had been put in place and these were provided to us. This meant the provider had taken steps to reduce the risk of harm to people.

Records showed people were given enough to eat and drink. People’s weight was monitored, and their risk of malnutrition was regularly assessed. When people were assessed as at risk of choking, care plans provided clear guidance for staff on how to reduce the risks, and what to do if a choking episode occurred. Staff knew what to do in the event of someone choking.

Clinical governance meetings took place monthly and risks to people were reviewed.

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 was visibly clean and well maintained. Staff were able to report any maintenance requirements. Equipment that we looked at was clean and fit for purpose. There was a well-maintained secure garden for people to use.

We reviewed records of checks carried out to ensure the premises were safe. This included gas, electrical and fire safety checks. Regular checks of equipment were carried out. Personal evacuation plans were in place. These were regularly reviewed to reflect people’s support needs in the event of needing to evacuate the building in an emergency. Regular fire drills were carried out and staff told us they attended fire training.

We received mixed feedback from people, relatives and staff in relation to staffing levels. Although some people told us they felt there was enough staff on duty, this was not consistent. Examples of comments included, “There’s enough staff to help” and “There always seemed to be staff around and I'm never looking for someone. We also see the housekeeping team and the laundry team around.” Other people and their relatives felt there weren’t enough staff. They told us “The staff are very good, but they just don’t have the time” and “Staff are definitely rushed.”

The provider used a dependency tool to calculate staffing levels, and the rota showed the service was slightly overstaffed. However, staff also told us they did not always have as much time as they would like, such as, “People are not getting proper care, we are rushing, and we cannot communicate with residents properly it’s just rushed.” Some staff told us they felt stressed and unable to provide person centred care. Minutes from a residents meeting in August 2025 showed that people had raised that they felt staff were rushed and did not have time to talk with them. Despite this, we saw that call bells were answered quickly and when we saw staff, they did not appear rushed. We fed this back to the management team during the inspection who confirmed that they reviewed staffing levels regularly as part of the providers monthly staffing review as well as carrying out daily walk rounds to observe for themselves the staffing levels. They also told us they held meetings with the whole staff team to review staffing levels, skill mix and dependencies to assure themselves the service was meeting the needs of people. They assured us they reviewed and amended staffing levels to ensure people’s needs were being met.

Safe recruitment processes were followed. Staff received regular supervisions from a line manager or supervisor and generally told us they felt supported in their role. Records showed staff were trained to carry out their roles.

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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.

The service was clean and well maintained. People and their relatives told us they were happy with the level of cleanliness. One person’s relative told us, “The cleanliness here is all fine. They [staff] hoover the room each day.”

Staff had completed relevant training in infection prevention. Staff knew when to put on personal protective equipment (PPE), and when to remove it. There was enough PPE available for staff to use.

Regular checks and audits were carried out. Cleaning equipment was safely stored when not in use. One member of the housekeeping team told us they felt supported, had access to training, and had all equipment they required to carry out their role.

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 were managed safely. The temperatures of storage areas including medicine fridges was monitored to ensure medicines were stored at the correct temperatures. Records showed people received their medicines as prescribed.

We observed part of a medicines round. The nurse administering the medicine to people was calm and took their time with people, making sure they had a drink to swallow any tablets. Medicines were administered by nurses who had completed training and had their competency assessed each year.

When people were prescribed additional medicines (PRN), there were protocols in place which described when and why people might need them. Staff had recorded the reasons why they had administered these and the outcome, which meant it was easy for them to monitor the effectiveness.

Topical medicines, such as creams and lotions were stored safely.

One person’s relative said, “They are very switched on with medication. When [name] first moved in, there were two tablets missing from medication and the staff got in touch with the GP surgery straight away and got these replaced.”