Rose Water Place Care 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. This is the first assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 were effective processes in place to record and report accidents and incidents. Staff recorded accidents and incidents on the clinical governance system to make sure there was an accurate record.

When accidents or incidents happened or were raised the registered manager completed investigations and shared any lessons learnt with staff through updates, meetings and reflective practice.Staff told us they were confident action would be taken when things went wrong, and they had received updates and feedback. Relatives told us action had been taken when their loved one had fallen, “(Relative) has had 2 unwitnessed falls in their bedroom and in the main lounge. It happened on a Wednesday, and we came in for a meeting and (registered manager) made it clear that measures had been put in place and were happy with that.”

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. People met with staff from the service before they moved in, to check staff could meet their needs. An assessment was completed covering all aspects of their lives and used to develop the person’s care plan and identify risks. When people were admitted to hospital, information about their care and support was sent with them including medicines. People were referred to healthcare professionals when required. We observed staff providing information to healthcare professionals over the phone to support health assessments and treatment.

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 told us they felt safe living at the service and relatives thought staff kept people safe.

The registered manager and staff understood their responsibilities to identify and raise safeguarding concerns with the local authority. Staff had received training and were able to describe different types of abuse and the action they would take. Staff told us they were confident to raise concerns with the management team and action would be taken.There was a record of safeguarding concerns which had been raised and reported. When appropriate, the management team had investigated the concerns and acted.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Individual risks had not always been identified and assessed to enable appropriate preventative measures to be put in place. However, we did not observe or find any evidence of negative impact on people and their care.

There were care plans in place with general information and did not contain specific individual risks. People who were living with Parkinson’s disease did not have a specific risk assessment in relation to how their condition affected them, including the importance of having their medicines at specific times, and the measures needed to reduce the risks. However, people had received medicines as prescribed, and risks had been identified in other areas of the care plan. Some people were living with epilepsy, there was some generalised guidance but this was not specific for staff to recognise a person’s individual seizures, if there were triggers and what to do in the event of a seizure. However, people had not experienced seizures since moving into the service and were managed by medication, which they had received as prescribed. There were moving and handling and bed rails assessments in place. However, a person had been identified as being at risk of falls, they had fallen without injury, but no further information about the risk had been included. But staff understood the risks and the action needed.

A relative told us about the equipment used to reduce the risk of their loved one falling, “(Relative) does have a good system of alarms in their room, pressure pads which alert the staff if they get up. They have a rollator but forgets and gets up. The staff are good and go quickly but can't always get there quickly enough.”

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 service was a new building and under a year old, all the required safety certificates were in place.The management team completed health and safety audits, a daily walk round the building was completed to make sure the environment was clean, odour free and safe.People had personal emergency evacuation plans in place to make sure people could be evacuated safely.

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. People told us, there were mainly enough staff, though at weekends and at night they sometimes had to wait longer when they pressed their call bell. People thought staff were well trained and knew how to support them safely.

There were processes in place to recruit staff safely, including references and Disclosure and Barring Service (DBS) checks. The provider had a training team in place, this team provided a mix of face to face, online classes and e-learning to make sure staff could meet people’s needs. Staff told us they were appropriately trained and could ask for more if they wished.The management team completed regular walk rounds to observe staff practice. When concerns were raised about staff practice, these had been investigated and action taken.

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, tidy and odour free. There was a housekeeping team who were on site every day. The housekeeping team were used to immediately address any potential infection risks promptly.Staff were observed wearing personal protective equipment (PPE) such as gloves and aprons. Supplies of PPE were available around the service.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines were not always managed safely. There were processes in place, but these had not always been followed. Some people were prescribed medicines on a ‘when required’ basis such as pain control. There was guidance in place about when to give the medicines, how often and what to do if they were not effective. However, the guidance was not always personalised, staff told us they were in the process of adding more information.

We randomly counted some people’s medicines and found they did not match the count on people’s records. We spoke with staff, who immediately investigated to make sure it was a recording error and people had received their medicines as prescribed. We received confirmation that this was the case.Some people’s medicine charts had handwritten amendments to the prescriptions. These had not been signed by 2 staff to confirm they were correct, following best practice guidance. Staff were responsive during the inspection and acted on the shortfalls found.

Some people received their medicines covertly. Records showed healthcare professionals had agreed to the decision and checked the safest way to give the medicines such if they can be crushed.People told us they received their medicines as prescribed and on time. One person told us, “Yes, they bring them to me when I should have them and if I ask for something for pain, they will get them for me.”