Rose House

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.

This is the first assessment for this service. This key question has been rated 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 service was in breach of legal regulation in relation to safe care and treatment and premises and equipment.

This service scored 53 (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.

There was an effective system in place to record accidents and incidents within the service.

Staff appropriately documented all incidents, which were then investigated by the management team. Root causes were identified to minimise the risk of recurrence and to support learning. This approach helped to ensure people were kept as safe as possible while using the service.

Staff were informed of investigation outcomes and lessons learned. They were encouraged to raise any concerns identified while providing care and support.

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.

The provider carried out an assessment before people started to receive care and support from the service to ensure they could be met.

People who used the service had been using the service for a very long time and no one had started using the service recently.

There was a procedure to follow when a person wished to start to use the service, including the scope of the assessment.

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.

People who were able to talk to us said they felt safe with the staff. A person told us, “Yes, I do feel safe,” when we asked them if they felt safe with staff. A relative told us, “I have noconcerns.”

The provider had appropriate policies and procedures in place to guide staff on how to respond to any allegations of abuse. Records confirmed that staff had received safeguarding training, which supported their knowledge and understanding of how to keep people safe.

Staff demonstrated a clear understanding of their roles and responsibilities in relation to safeguarding and reporting concerns. They were able to explain which external agencies they would contact without delay if they witnessed, were informed of, or suspected that a person using the service was being harmed or placed at risk. A member of staff told us, “I will report any abuse to the manager.”

The registered manager was aware of their responsibilities in ensuring people were protected from abuse.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider did not ensure all risks to people’s safety and wellbeing were identified or provided enough detail as to how these should be mitigated. For example, where people could become anxious, distressed and exhibited behaviours that could place themselves and others at risk of harm.

Risk assessment completed for personal care did not provide staff with clear guidance about what course of action to take for a person who may become physically aggressive while they were in bath or bathroom. This omission may place both the person and staff at risk.

The provider showed us a diabetes risk assessment which they had recently been completed for a person on a new digital system. However, this system had not yet been implemented for staff to use. The registered manager confirmed that there was no hard copy of the diabetes risk assessment available during our visit for staff to follow. A staff member told us they were not aware that a digital care planning system was being introduced. Consequently, the electronic risk assessment was not accessible to all staff.

We also noted no risk assessment had been completed for house chores. For example, a person who was not aware of their surroundings and associated risks, enjoys doing house chores e.g. vacuum cleaning. No risk assessment was completed to assess any potential risks to the person. A care plan we reviewed stated that a positive behaviour support (PBS) approach was required to manage a person’s agitation and behaviours that challenge. However, we found there was no PBS plan in place.

The care plan and associated risk assessment did not clarify whether this approach was being implemented. In addition, the risk assessment developed to manage behaviours that challenge was ineffective, as it failed to provide staff with clear guidance on the techniques and strategies to use when responding to such incidents.

The same person required one-to-one support when accessing the community. However, the associated risk assessment did not reflect this requirement. Instead, it only stated that the person needed close supervision, without clearly specifying that one-to-one support was necessary.

Another person was assessed at risk of scalding with hot food and drinks. However, the provider did not always check the food temperature before serving. This put people at risk.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The management team carried out checks to identify any potential hazards in the service and put measures in place to mitigate those risks. However, we found the system was not robust enough to demonstrate safety was effectively managed.

The emergency exit fire door in the utility room was jammed and could not be opened. The team leader struggled but eventually managed to open the fire door. This put people at risk in the event of an emergency as they may not be able to escape. The fire door had been fixed by the time of our second visit.

We also found the light to the top floor was not working. The team leader went downstairs and adjusted something, after which the light began to work. This meant the person whose room was on that floor was at risk of trips or falls as the area was dark when the light was not functioning. On our second visit, we saw the provider had taken action and installed a new sensor light which activates automatically when it detects movement.

We observed checks had been carried out on the electrical wiring and gas appliances. Legionella testing was carried out and no concerns were identified.

People had a personal emergency evacuation plan (PEEP) in place. This is guidance for staff on what to do in the event of an emergency, and how to safely evacuate people,

The provider told us that that refurbishment work of the home was underway. For example, they planned to change the flooring in people’s bedrooms and the office floor.

The provider did not always make sure there were enough qualified, skilled and experienced staff.

On our first visit, 4 people were using the service, and 2 staff members were on duty. We noticed that a person who was unsettled, came to the kitchen on a number of occasions. The person was not able to communicate verbally. The staff tried to make them comfortable and engage them in activities.

We noted that staff were having 30 minutes breaks. If the staff decided to leave the service during their break, this meant there was only 1 staff member supporting 4 people. This meant if there was an emergency situation where 2 staff were needed, this may put people at risk. The provider told us that they would review the staffing level and break times to ensure people needs were met safely.

A person was assessed as requiring 5 hours of one-to-one support per day. The registered manager told us that there was no set time schedule for when this one to one support would be delivered during the day. We reviewed the records and found that the timing of one-to-one support varied throughout the day. We also saw that, on 30/01/26, the person received only one hour of one-to-one support.

We also identified issues with the one-to-one records. On a number of occasions, records had been crossed out or changed. This made it difficult to determine whether the person had received the required one-to-one support on those days. We brought this to the provider’s attention, they said they would address the concerns.

We found people were supported by the same group of staff members who were familiar with their care needs. This helped with consistency and continuity of care as staff were aware of the needs of people they were caring for.

The provider had effective recruitment and selection processes in place to ensure people were protected from the risk of receiving care from unsuitable staff. We reviewed staff recruitment files and found that all required pre-employment checks had been completed. The files contained application forms, references, identity checks, and evidence of criminal record checks.

The provider had a training programme in place to ensure staff had the skills and knowledge required to meet people’s needs. Staff completed training in key areas including moving and handling, infection control, fire safety, food hygiene, and conflict management, which helped ensure they were competent in their roles. Staff had also completed to develop a better understanding of the needs of people with a learning disability and/or autistic people.

The provider told us that 3 staff members were enrolled on to a level 2 qualification in health and social care. The registered manager was also about to complete their level 5 qualification in health and social care by the end of February 2026.

New staff received an induction when they started working at the service. This included training, familiarisation with policies and procedures, and time to get to know people who used the service. New staff were supported to shadow experienced staff before working independently.

Staff had regular supervisions with their line manager, where they could discuss any concerns or issues. These meetings covered topics such as training needs, personal matters that may affect performance, and the needs of people using the service. Staff told us they felt well supported by the management team.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading.

The provider did not have an effective approach to assessing and managing the risk of infection as we identified some concerns during our visits.

On the first day of our visit, we found unlabelled and uncovered food in the fridge, and this posed a significant breach of food safety and hygiene regulations, presenting high risks to people who used the service. Uncovered food can easily become contaminated with bacteria and food stored in a fridge must be labelled with the date it was opened or prepared, and the date it must be used by. We noted the same concern during our second visit. We brought this to the attention of the provider who assured us they would take action to remind staff of their responsibilities regarding infection control and prevention.

We found food temperatures were not always being monitored. There were missing entries. The food temperature records were completed every day. However, in the month of January 2026, up until 28/01/26, only 12 entries indicated the food temperature was recorded as 85 and 86 degrees. For the other days, the records were written was ‘N/A.’ Serving food at the wrong temperature is a major food safety risk that allows bacteria like Salmonella, E. coli, and Listeria to multiply rapidly. This put people who used the service at risk of avoidable harm.

We noted the infection control and prevention (IPC) team visited the service to conduct an inspection on 02/02/2024 and made some recommendations. We found not all the recommendations had been implemented. For example, it was recommended that the provider should produce an annual IPC statement, but the provider had not done this. This meant the provider was not able to demonstrate compliance with infection prevention and control best practices and standard.

Staff had received training in infection control. They conducted hand hygiene competencies assessment for staff. There was a deep cleaning schedule in place for the service.

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

Systems were not robust enough to demonstrate medicines were managed safely and effectively. This placed people at risk of harm.

The provider used a digital electronic system for medicine management. Information about what medicines people were prescribed were within the care records.

We found 2 medicines which were prescribed on a ‘when required’ basis (PRN) were expired. This meant people were at risk of having expired medicines as staff were not aware the medicines had expired. We could not ascertain whether a person had been administered one of the expired medicines as the medicine was administered last year.

Some protocols were in place for medicines prescribed on a ‘when required’ basis (PRN), to enable staff give these medicines. However, these were not detailed and did not inform on the actions staff needed to take if the medicine did not work. For example, who to call for advice. For a person who was prescribed Diazepam as required, there was no protocol in place. Another person was prescribed Paracetamol as required and again no protocol was in place.

Following our first visit, PRN protocol for lorazepam was put in place. However, the PRN protocol did not highlight that staff should complete behaviour chart to record the symptoms prior and post medicine administration.

We also found the provider did not have a controlled drug cabinet in place to keep controlled drug medicines placing people at risk of inappropriate access or misuse. This meant the provider was not complying with the regulations around storage of controlled drugs. This was put in place on our second visit.

One of the medicine cabinets was not secured properly to the wall which was a risk to staff who administered medicines. This was brought to the attention on the provider who had the cupboard fixed the same day.

People were supported with their medicines by staff whose competency to administer people’s medicines had been assessed.

Medicines audits were carried out by the management team to ensure people had received their medicines as prescribed. However, this was not working effectively as they did not identify the concerns we did, during our visit.