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.

At our last assessment we rated this key question good. At this assessment the rating has remained 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 promoted a culture of safety and learning that supported people to live confident and empowered lives. Staff reflected on incidents and used them to improve care, with clear documentation of actions taken and lessons learnt. This approach helped reduce future risks and supported people’s rights to live safely and with dignity. Staff described feeling supported to raise concerns and contribute to improvements, which reflects a culture of openness and accountability.

People experienced safe transitions and care pathways that respected their choices and promoted independence. Care plans were detailed and person-centred, supporting people with complex needs such as dementia, epilepsy and diabetes. Staff worked with health professionals and families to ensure continuity of care, including hospital passports and end-of-life planning. The service adapted to people’s changing needs, ensuring they remained at the centre of decisions about their care.

People were protected from abuse and improper treatment. They could tell us who they would raise concerns with. Staff understood safeguarding procedures and acted promptly when concerns arose and updating risk assessments. People were supported to express themselves and staff recognised signs of distress. Staff used personalised approaches to reduce restrictive practices and promote people’s rights, in line with the ethos of current best practices.

People were actively involved in managing risks that affected their lives. When they were unable to be involved those important to them were. Staff supported people to make choices about their daily routines, such as preparing drinks or choosing meals, and adapted support to individual preferences. Risk assessments were personalised and focused on enabling independence while keeping people safe. Staff respected people’s decisions, promoting dignity and control in line with the latest guidance.

However, due to the lack of specialist training there was a tendency for staff to have a risk averse approach to supporting people.

The environment did not always support people’s safety or dignity. While the home was homely and personalised, some areas required improvement. For example, bedroom doors were propped open inappropriately leaving people at risk in the event of a fire. One partially exposed bed rail posed risks of entrapment. Action was taken by the provider to ensure the physical environment consistently met people’s safety needs.

Visual methods were not in place around the home to support sight loss, dementia, learning disabilities and autism. For example, contrasting door frame colours and symbol or picture labels to encourage independence. This limited the service’s ability to fully uphold current best practice principles.

People with failing mobility and who used bespoke equipment did not always live in an accessible, safe environment. One person could not have staff travel in the lift with them due to a large wheelchair. Another person told us they could not access the kitchen due to a step. The registered manager explained they had linked with a local charity for a person with sight loss. They continued the methods had not always been successful around adaptations to the environment and equipment. There were risk assessments in place, and the management were already trying to find solutions to issues. For example, placing people on the ground floor with limited mobility.

However, systems were in place to keep people safe in the event of a fire. All health and safety checks were in date and no concerns were identified.

Staffing arrangements did not always support safe and person-centred care. People said they would like to go out more but could not due to staff shortages. One person said, “I would like to go to the beach, but we do not have the staff.” Night staffing was limited, with only 1 staff member trained in medicines administration. Plans were in place by the provider to rectify this. The provider recognised people’s needs were changing so were in the process of reviewing needs to increase staffing levels.

Although staff felt supported and described a positive team culture, gaps in specialist training around learning disabilities and autism were found. For example, staff had limited knowledge on autism specific strategies and how to reduce people’s anxiety. These issues potentially impacted people’s access to the community and limited their choices. This did not fully reflect the principles of Right support, right care, right culture. New members of the provider had already recognised these issues and plans were in place to resolve these issues. This included increasing staff training around autism, learning disabilities and dementia.

However, recruitment of staff was in line with legislation to keep people safe.

Infection control practices were safe and effective. Staff followed hygiene protocols and used protective equipment appropriately. People with respiratory conditions were supported safely, and the environment was clean and well maintained. These practices helped protect people’s health and upheld their right to safe care.

Medicines were managed safely and in line with best practice. Staff followed protocols for administering time-specific medicines and used competency checks to ensure safe practice. Controlled drugs were stored securely, and fridge temperatures were monitored. People were supported to understand their medicines, and staff adapted support to individual needs, such as managing diabetes or using thickened drinks. Minor issues, such as a broken trolley lock, were being addressed. Overall, people received their medicines as prescribed, supporting their health and independence in line with current best practice.