Rose Court Care 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. This is the first assessment for this service under the new provider. This key question has been rated 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 the legal regulation in relation to good governance, because the provider’s systems for monitoring and improving quality were not always effective. This was because the quality assurance processes and medicines audits had not identified the issues we found during this assessment.

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 effective systems to manage complaints, accidents and incidents. The management team completed regular detailed analyses of events to establish themes and trends and support lessons learned.The registered manager told us lessons learned were discussed with staff during handovers, staff meetings and supervisions. This reflective approach helped ensure people were kept safe from harm and continued to drive improvement in the service.

The registered manager and team were open and responsive to feedback and advice throughout the inspection. They also worked well with external partners to review practice.

Overall, people and staff spoke positively about the leadership of the service, stating the registered manager and management team were visible and supportive and well led. They commented the home was enjoyable to work in and considered the management to be good and supportive.

There were capable and inclusive leaders and leaders had the skills, knowledge, experience and credibility to lead effectively. The Management understood the duty of candour. They learnt from mistakes and were open and honest with relatives, people who used the service, the local authority and CQC.

The registered manager was visible and had an ‘open door’ policy whereby they encouraged people using the service, relatives and staff to speak with them about any issues. For example, staff told us they discussed their concerns or work-related issues, including staffing levels, in staff team meetings. The Service provider had recently an implemented a new dependency tool and was currently reviewing their staffing levels, which helped demonstrate that staff’s views were taken on board.

The register manager told us they had been supported by the provider. They undertook continuous learning and development to increase their skills and knowledge and encouraged the whole staff team to do the same.

The registered manager said the operational manager was in the home frequently. An action plan was in place to drive forward the identified improvements. Staff spoke positively about the management team. A staff member said, “The [registered manager] is supportive and if I have any issues, I speak to them.”

People, their relatives and staff told us they would feel able to speak up if they had any concerns. The provider had a whistleblowing policy and procedure in place for staff to follow and information was available to staff about how and where to raise concerns. There were systems to enable staff and others to speak up when something was wrong. Staff were aware of the provider’s whistleblowing procedure and told us they would report poor practice to team leaders and the registered manager if they needed to. A staff member told us, “Happy to use the whistleblowing procedure if needed.”

Management operated an open-door policy and welcomed feedback from staff. Staff felt the registered manager supported and listened to them. Staff also had regular meetings and used these to contribute information about their experiences and listen to feedback from others.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for staff who worked for them. Policies and procedures were in place to support leaders in managing staffs’ needs and help ensure equity of opportunity in the workplace.

The manager shared examples of how support and adjustments were made to accommodate staff members’ personal situations and promote their wellbeing. Staff told us reasonable adjustments were made to support their specific needs. For example, wearing an alternativestaff uniform to support them through their specific health condition and changes in the staff rota to accommodate their religious and cultural events, such as Diwali and Ramadan etc.

Improvement was required in relation oversight and governance of medicines.

Leaders acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. However, there was a lack of robust oversight and governance in relation to medicines management, as their audits had not identified the gaps or concerns, we found during this assessment around medicines practices

On the day of our assessment, we provided the management team with feedback about our findings. They undertook an internal investigation, and an investigation report was provided to us.

The provider had quality assurance processes in place to help maintain oversight and ensure the delivery of good quality and sustainable care, treatment and support. The provider had a comprehensive suite of quality assurance audits that were completed by leaders. These covered a variety of areas including wounds, falls, accidents and incidents, the environment, and care plans

The provider worked well with other healthcare professionals. They followed guidance and recommendations from those people, to support staff learning and improve the safety and quality of the delivery of people’s care and support.

People and relatives told us they were supported to access other professionals. A relative said, “[Person] has access to healthcare professionals when needed and I am kept updated.” A person told us, “The staff are good and that makes me feel safe and secure. If I need help, they are there. If I need hospital, someone goes with me.” Another person told us, “The doctor checked me out yesterday.” We observed health professionals such as District Nurses in the home on the day of our visit.

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

The provider had evaluation audits to support their awareness of what was working well within the service and what areas needed improvements. Management Audits reviewed incidents, investigations and monthly analyses of events to establish themes and trends.

The registered manager used learning from feedback and outcomes from audits and checks, to make improvements to the quality and safety of the care and support provided to people. However, we identified further improvements were needed with medicines audits.

The home had compiled detailed improvement plans, and we saw examples of where improvements had been made to the service.