Rose House

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. 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 legal regulation in relation to good governance.

This service scored 61 (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.

The registered manager operated an open-door policy, allowing people, their relatives, and staff to speak with them at any time.

Staff reported that the registered manager was approachable and easy to talk to if they needed to raise any concerns.

Staff demonstrated a clear understanding of the ethos of the service and were confident in their responsibilities. They understood their roles and felt well supported by the management team.

The provider told us they wanted to expand and wish to acquire more care homes to provide services especially for people with a learning disability. In addition, they said that they would like to continue to provide safe and comfortable environment to the people living at Rose House.

Not all leaders understood the context in which the provider delivered care, treatment and support.

The registered manager fostered positive relationships with both staff and people using the service, as well as their families. Staff described the registered manager as approachable and receptive, making it easy to discuss any concerns. Overall, staff expressed satisfaction it was noted that staff did not always follow the instructions provided by the registered manager. This inconsistency meant that the registered manager did not have proper oversight of the running of the service which may have an impact on the quality-of-care people received.

There were systems in place for communication between staff and the management of the service through staff meetings, staff handovers and a digital application. Despite these systems, not all information was successfully passed on to staff. For example, the introduction of a new care planning system was not adequately communicated, resulting in some staff members being unaware of the change. This meant robust protocols were not in place to ensure that significant updates, especially those affecting day-to-day operations and care provision, were effectively relayed to all relevant staff.

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

The service had a whistleblowing policy which gave guidance to staff about who they could speak to should they have any concerns.

Staff reported feeling confident to speak openly and raise any concerns with the management team.

Relatives also told us they would feel comfortable approaching staff or management if they had any concerns about the service.

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.

The registered manager actively encouraged staff to participate in how the service was run. There were regular staff meetings held where staff could raise concerns, discuss issues, and share suggestions for improvement. However, we noted the provider had not informed the staff about the new digital system being introduced.

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

Robust good governance systems were not in place to ensure management had oversight of the service.

Systems were not always effective in assessing, identifying and managing risks to people. People’s medicines were not always managed safely. The provider’s system to manage confidential records had not ensured that confidential information was always kept securely. The systems to identify any potential environmental hazards in the service and put measures in place to mitigate those risks were not effective. Food hygiene principles were not being followed. No consent forms for care and support were completed. People did not always receive personalised care that was responsive to their health care needs.

The registered manager showed us their completed audits. These included IPC, first aid and medicines audits. This meant the audits the provider carried out were not effective due to the shortfalls we found around medicine management and IPC.

No other audits such as health and safety, dignity, moving and handling, fluids and nutrition, care planning, hand hygiene (although hand hygiene competencies assessments for 3 staff members were completed).

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

People 's needs were monitored on a continual basis. The management team worked well with other health and social care professionals to ensure people’s changing needs were being met. Records showed people had been referred to different health care professionals as and when required.

The management team worked closely with the local authority and other professionals to ensure continuous improvement in the care and support provided to people. They recognized the importance of maintaining strong, ongoing professional relationships with individual practitioners to support coordinated and effective care.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

The management team worked well with other health and social care professionals to ensure people’s changing needs were being met. Records showed people had been referred to different health care professionals as and when required.

The management team worked closely with the local authority and other professionals to ensure continuous improvement in the care and support provided to people. They recognized the importance of maintaining strong, ongoing professional relationships with individual practitioners to support coordinated and effective care.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

Although the provider sought feedback from people using the service, their relatives, staff and other professionals through satisfaction surveys, the information gathered was not analysed to identify themes or drive improvement. As a result, opportunities to monitor and enhance the quality of care were missed. We discussed this with the registered manager who acknowledged and said they would address this issue.

We saw the area manager visited the service to identify where improvements were needed. An action plan was implemented with timescales to be completed. For example, we found the issue around food labelling was identified. The registered manager had emailed staff to remind them about labelling food in the fridge. However, we found staff were not doing so during on both visits meaning staff were not adhering to the instructions given by the registered manager.