Rose Cottage Nursing 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.

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

This meant systems and processes were not fully embedded to ensure effective governance at the service.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 62 (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 described the culture as being ‘supportive’ and a ‘family orientated environment, where people are safe and being well cared for.’ Staff had been working at the service for a long period of time and were available to cover absences for other staff, so agency was not used. Staff also told us there was a good structure in place where all staff knew what their roles and responsibilities were which ensured the service operated effectively.

People, relatives and professionals all told us the culture at the service was ‘Caring.’

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. They did so with integrity, openness and honesty.

The registered manager understood their regulatory responsibilities in reporting and acting on concerns raised. They also had a detailed understanding of each person living in the service and their individual needs.

The shortfalls identified in the governance systems at the last assessment had been resolved and although we found different shortfalls during this assessment, the registered manager was responsive and made amendments when we raised these.

Staff, people, relatives and professionals all provided positive comments about the registered manager and the way in which they managed the service. For example, one staff member commented, “It’s a very open-door policy here, we have a very passionate manager who accommodates people's needs at the last minute this includes, staff, people and family members.”

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

Staff told us they were able to speak with the registered manager about any concerns they had and knew of other agencies they could raise concerns to, outside of the organisation. Staff had regular opportunities for one-to-one discussions and team meetings.

The provider had a whistleblowing policy and information available on a notice board within the home about the various ways people could speak up about any concerns they had.

The registered manager told us, “We are a close team and working environment, my door is always open for anyone to raise concerns, I follow our open culture policy. If staff want to talk to me, I am open and approachable.”

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.

Staff told us they felt they were treated fairly and with respect. Some staff described situations where adjustments had been made to their working patterns to accommodate emergencies.

Staff felt the service was inclusive and everyone was supportive of each other. Staff did not feel there was any bullying or harassment and had received training in equality, diversity and inclusion. There was an equality, diversity and inclusion policy available.

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.

At the previous assessment, concerns had been identified regarding governance systems and processes. Whilst some improvements had been made in areas we had identified at the last assessment, we found several new concerns in areas we had not previously identified. The provider completed regular audits and checks; however, these were not effective in identifying the concerns found during this assessment. This included failures to identify omissions and inconsistencies within care plans and risk assessments, environmental safety risks, shortcomings in medicines management, and areas where risks to people's safety had not been appropriately assessed or managed.

Information required to monitor the quality and safety of the service was not always readily accessible through the systems in place at the time of the assessment. Although documentation could be produced when requested, governance processes were not sufficiently robust to enable effective oversight and timely identification of concerns.

The registered manager took immediate action to address some of the issues identified during the assessment and outlined plans to introduce a digital governance system to strengthen monitoring and oversight. However, these improvements had not been implemented or embedded in practice at the time of the assessment. As a result, the provider could not be assured that governance systems were effective in identifying and addressing risks and driving sustained improvement.

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.

We saw evidence of other professional involvement in people’s care through records we reviewed. Relatives told us people were supported by external health professionals and said people were supported with hospital appointments by staff when needed.

One professional working with the service commented, “Rose Cottage works positively with external healthcare professionals and values collaborative working. They are receptive to feedback and recommendations and actively engage in a joined-up approach to resident care. Their openness to professional advice and willingness to work collaboratively contributes positively to resident outcomes and service development.”

The service was in a small village area, where the community worked together to support people. For example, the local Church provided a regular religious service to people in the home and provided a safe place for them to go in the event of a fire or emergency evacuation. The provider organised an annual barbeque for people and their relatives to attend. They told us they enjoyed this event.

The provider had systems in place to support learning, improvement and service development. However, opportunities to demonstrate how learning was consistently embedded, evaluated and sustained across the service were not always evident.

At the previous assessment, we identified shortfalls in the provider’s governance arrangements. Whilst some improvements had been made, new concerns were identified during this assessment. These had not been recognised through the provider’s own monitoring systems and were only addressed following feedback from the assessment. This indicated that opportunities to learn from existing systems and proactively identify areas for improvement had been missed.

However, the provider had taken steps to improve service delivery since the last assessment. A new electronic care planning system had been introduced to improve the accessibility and management of care records for staff and visiting professionals. The provider had also engaged an external quality assurance organisation to review policies, procedures and health and safety risk assessments.

Following feedback received during this assessment, the provider committed to introducing a new governance and auditing system to strengthen oversight and improve the effectiveness of quality assurance processes. Whilst these developments were positive, they had not yet been fully implemented or embedded in practice.

The provider also demonstrated a commitment to staff development. Although the provider did not have anyone living in the service with a learning disability, they had put training in place for all staff on the governments recommended training to enhance staff’s training and knowledge.