Rose Cottage Nursing 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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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 at the service.

This service scored 59 (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.

People and their relatives told us they could raise any concerns with staff and management and felt these would be acted on. Relatives told us the service always updated them when an incident happened and what they had done about it, which made them feel reassured.

One professional told us, “The service communicates safety concerns and clinical incidents appropriately and in a timely manner via referral and email. The team collaborates with external healthcare providers to investigate issues and implement actions to reduce future risk.”

At the last assessment of the service, we identified trends for accidents and incidents were not carried out and no lessons were learnt. At this assessment we found improvement had been made. For example, we observed records where each incident had a good level of detail, the actions taken and lessons learned. Monthly analysis of incidents and accidents were also being completed and shared with staff teams.

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 told us they had received support from different professionals when they moved into the service, this included hospital liaison staff and social workers. People and their relatives felt the initial assessment of needs had been completed thoroughly. One person told us, “The transfer went well, I was able to express my needs and wants. My [Spouse] really rates the manager and said they explained everything about being admitted and all the plans put in place.”

One professional told us, “I have found the staff to actively seek advice when residents deteriorate or when additional specialist input is required. They work well with healthcare professionals to ensure transitions between services are coordinated and resident needs are met.”

There was evidence of comprehensive assessments being completed of people’s needs to support with safe pathways and transitions.

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 and their relatives told us people were safe living in the service. Comments included, “I am absolutely sure [Person] is safe,” and “I am happy [Person] is safe, lots of relatives go in to see them and no-one has seen anything wrong at all.” Relatives said they were kept updated about any concerns.

Staff and leaders understood their responsibilities in raising safeguarding concerns. Safeguarding documentation was well maintained, accurate and evidenced files we reviewed. Staff received annual training in safeguarding and the Mental Capacity Act (MCA) and there was a safeguarding policy and procedure available.

Where appropriate the provider had applied to the local authority for Deprivation of Liberty Safeguards (DoLS) authorisations. The manager had a record of all DoLS applications that had been made, including details of any conditions to the authorisations.

Documentation did not always reflect people’s risks. As a result, people could potentially be exposed to harm.

We identified a lack of information in 1 person’s care plan in relation to oxygen use to ensure staff had the information available to manage the risks. This included a lack of information about the interaction between the fire risks of using emollient based creams and other products. This meant that all the risk relating to oxygen use had not been considered or mitigated, potentially placing the person and others at increased risk of harm.

We also identified 1 person’s choking risk assessment did not indicate the risks associated with a diagnosed condition. This meant the person's underlying risk of choking had not been fully considered or accurately reflected within their risk assessment. We did not identify any harm had come to the person because of this information not being accurate. When we pointed these concerns out to the registered manager they made amendments.

However, people and their relatives told us the provider helped manage risks for people. For example, one relative told us, “[Person] is at risk of Urinary Tract Infections (UTI's) and they are on it. They'll call the GP or they'll take a sample to make sure they get the right medicine.”

Most people’s care plans and risk assessments contained sufficient information to help staff identify risks for people. This included people with specific health diagnosis such as diabetes. Staff showed an awareness of how to manage risks for people and staff knew people and their needs well.

The provider did not effectively 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.

Hazardous areas were not always secured appropriately. During the assessment, we found unlocked sluice rooms (a dedicated space designed to manage potentially infectious waste in a service) and a laundry room accessible to people living at the service, with chemical substances stored inside. This created a risk of unauthorised access to potentially harmful substances. Although the registered manager took immediate action to secure the sluice room, the key was later found left in the door, meaning access remained possible. They could not find a key to the laundry room and told us they needed to replace the lock.

Environmental hazards were also present within communal areas. We observed protruding nails on a radiator cover in a communal bathroom, which posed a risk of injury to people. While no incidents of harm had been recorded, action was only taken after this was identified during the assessment.

Emergency evacuation arrangements were not robust. Information within the Business Continuity Plan (BCP) conflicted with individuals’ Personal Emergency Evacuation Plans (PEEPs), resulting in inconsistent guidance for staff about how people should be evacuated during an emergency. For example, some records stated people required support from staff to evacuate, while other documentation instructed staff to leave them in place until the fire service arrived. In addition, the BCP contained inaccurate and outdated information, including details of people who no longer lived at the service and omissions of current people living at the service. As a result, the provider could not be assured people would be evacuated safely and in accordance with their needs during an emergency. The registered manager took action to review and amend the documentation following our feedback. However, we saw staff had completed scenario-based fire safety training and regular fire drills were being undertaken. Staff we spoke with knew how to support people to exit the building in the event of a fire and told us they would follow the instruction in people’s PEEPs in the fire grab bag.

Some areas in the home had been well maintained, and this included people’s bedrooms. However, we observed some areas where maintenance could be improved, for example, scuffed skirting boards and door frames. We fed this back to the registered manager who told us they were in the process of updating certain parts of the home and this work was on-going.

However, people had access to the equipment they needed. People and their relatives told us people were safe whilst using equipment. All required health, safety and maintenance checks had been completed. We saw window restrictors to prevent the risk of falls from height and wardrobes were attached to walls to prevent the risk of falling on people.

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.

Required recruitment checks had been completed for staff, this included references and Disclosure Barring Certificates (DBS). Gaps in employment history had been explored and noted, where necessary. At the last assessment shortfalls were identified in relation to staff training, at this assessment we did not identify these concerns and staff had access to relevant training to be effective in their roles.

Staff had access to regular supervision and team meetings to support them in their roles.

Relative provided positive comments about staffing levels, which included, “I see plenty of staff about when I visit,” and “There is always staff about and we know them.”

Staff commented they had enough time to meet people needs and if there were any emergencies, the registered manager would provide assistant. We observed staff were busy and this was confirmed by some people living in the service.

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

We identified some concerns regarding infection, prevention and control (IPC) practices. For example, we observed 2 dirty communal toilets which were unclean and had not been cleaned. The registered manager explained the housekeeping staff had started their shift later that day. We observed later in the day these toilets were clean.

We also saw an open container of cream on a shelf in a communal bathroom. The container was externally soiled and was not labelled for any personal use. In addition, we observed unlabelled toiletries and a sponge stored in a communal bathroom. As these items were open and accessible for communal use, there was risk they could contribute to poor IPC practice. The registered manager removed the items during the inspection.

However, people and their relative provided positive comments about the cleanliness of the service. Comments included, “The place is always clean and tidy,” and “It is always clean and tidy especially in [Persons] room.” People told us staff wore appropriate personal protective equipment (PPE) including gloves and aprons, and we observed this in practice. Staff had received IPC training and there was a policy available for staff to follow.

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

At the last assessment we found shortfalls in relation to medicine management, at this assessment we still found some shortfalls.

We observed a staff member administering medicines who did not clean or sanitise their hands or clean the medicines tray between administrations. We also observed that there were no handwashing facilities or clinical wipes available within the medicines room. This meant appropriate IPC measures were not being consistently followed during medicine administration, increasing the risk of cross-contamination. Following feedback, the staff member immediately undertook the required hand hygiene and cleaning practices.

We further observed that a cracked medicines tray was being used during medicines administration. The condition of the tray presented a potential IPC risk, as damaged equipment may be more difficult to clean effectively. Once this was brought to staff's attention, the tray was replaced promptly. The registered manager told us they had identified the cracked tray during the last audits and asked staff to remove it, which had not been completed. They advised they had issued a memorandum to all staff responsible for administering medicines and would be repeating medicines training and competency assessments to reinforce safe practice.

However, we observed several areas of good practice during medicines administration. Staff explained medicines to people in an appropriate way. Medication Administration Records (MARs) were checked before medicines were administered, and staff referred to relevant medicines information where required. Arrangements requiring two staff members to administer medicines were followed appropriately. The medicines trolley was secured between each stage of administration, reducing the risk of unauthorised access. MAR records were completed accurately, and medicines room temperatures were appropriately monitored and recorded. Medicines requiring specific storage and temperature monitoring were stored safely and managed effectively.