Rose Water Place 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 newly registered service. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (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, engagement, and understanding challenges and the needs of people and their communities.

Staff understood and were clear about the provider’s vision. They understood the ‘Barchester Way’ including support should be person centred and meet people’s needs. A staff newsletter had been produced containing information, for example, about the principles of safeguarding and how to report this. Staff were encouraged to nominate a colleague for employee of the month.There were ‘resident ambassadors’, where a person attended meetings to represent the views of people and offer suggestions.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. The provider had a management structure in place, regional managers visited the service regularly.

There was an experienced registered manager in post. Staff were complimentary about the registered manager stating they were open, friendly and could be approached at any time. Staff knew the reporting structure and felt there was support at all levels of management.Staff completed a comprehensive induction, most staff completed this before the service opened, and people moved in. Staff told us they received supportive supervisions, where their career development was discussed.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had introduced the role of ‘speak up champions.’ These were nominated members of staff which people, their relatives or other staff could go to if they were concerned about something.

Staff understood about whistle blowing and the reporting process within the provider. Staff would go to their senior managers if they thought the registered manager had not acted appropriately. Staff were confident to speak up and action would be taken.

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 provider had equality, diversity and inclusion policies in place, which staff were aware of.The staff group included staff from different ethnic and cultural backgrounds. Staff told us they felt they were treated fairly and equally.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. There were processes in place, but these were not always effective or comprehensive in identifying shortfalls.

The provider’s electronic care planning and monitoring system had an auditing function, however, this had not been used to check the system was being utilised correctly. There was no monitoring system in place to check the quality, accuracy or if the care plans were person centred. The shortfalls found in some care plans at this inspection had not been identified. The management team told us they did not have a quality monitoring system to check people’s care records. They had concentrated on how the new system was being used and quality checking would be the next step.

Staff completed monthly medicine audits, they had not identified the issues found at this inspection, where medicine in stock did not always match the records. There was not a system in place for the management team to check the audits completed by staff to check they were accurate.

The registered manager had recognised when staff performance had not met expectations and had acted to support them. The provider had policies in place to support staff to provide the care and support the provider expected.The service had submitted notifications about incidents and events to CQC, as required.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The service hosted a wide range of community groups in a communal area of the service which residents could attend. The service collaborated with local groups and welcomed the community into the service.Staff worked with healthcare professionals to provide joined up care for people.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. The provider did not give us the opportunity to review recent quality audits to assess if learning had taken place.

The service had been using the electronic care planning system for nearly a year. However, the provider had not worked out how to use the system to benefit partnership working and information sharing to improve outcomes for people, following the wishes of individuals and how their information was used and shared.