Rosebank 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

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 changed to good.

Good: This meant people were safe and protected from avoidable harm.

The residence was safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well. 

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The service had a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.   

Staff had access to an electronic reporting incident system. Staff we spoke with knew what incidents to report and how to report them.

There were 98 incidents between March 2026 and May 2026, common themes were medication errors, slip trips and falls, security and self-harm. Incidents were discussed at clinical governance meetings, staff meetings and community meetings and there was a lessons learnt log. 

Rosebank house undertook a QI project where they reviewed the number of absence without official leave (AWOL) related incidents to better understand why this was happening. Lessons learned from this project led to increasing the length of leave according to individual patients’ needs and risk assessments. This  reduced the number of incidents of AWOLs. 

Patients’ were involved in meetings such as clinical governance meetings, we reviewed 3 months of clinical governance meeting minutes and saw patient participation. This meant there was a partnership between patients and the service on developments and chances.

Staff told us they discussed incidents at monthly supervision. 

At the time of inspection, 100% of staff had received duty of candour level 2 training. Duty of candour mandates health and social care providers to be open and honest with people about their care and promotes a culture of learning.

The service work with people and their partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. The service ensured continuity of care, including when people move between different services.

The service 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.

The service’s referral and admission processes ensured that essential information about the patient was received to determine if the patient’s needs could be safely met. There was a clear care pathway in place from admission through to discharge. 

We observed a staff handover during which the patient's discharge progress was discussed. Staff shared updates that had been provided to the patient and outlined plans to discuss discharge arrangements with the patient's family. During this meeting the family’s request for a potential discharge destination closer to the patient's family was discussed and considered.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. 

Staff worked collaboratively across the wider system to ensure patients' needs were met throughout their care pathways. Staff members we spoke with described examples of providing follow-up support to patients following discharge, including supporting a recently discharged patient with their transition back into the community.

The service work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

The evidence showed a good standard; the service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff worked with other services and stakeholders to protect people from avoidable harm and abuse. There were systems and processes in place to protect from abuse and neglect. Staff followed the provider’s Safeguarding policy, including the provider’s sexual safety policy.

All staff had completed their safeguarding training appropriate for their roles. Staff knew how to make a safeguarding referral and did that when appropriate. Staff knew how to identify adults and children at risk of, or suffering, significant harm. 

We observed staff discussing an ongoing safeguarding concern relating to a patient requesting leave, with consideration given to associated risks. Staff also discussed previously closed safeguarding referrals, demonstrating an understanding of safeguarding procedures and their responsibilities in protecting patients.

Staff members we spoke with were able to clearly describe the safeguarding process, including how to recognise safeguarding concerns, escalate risks, and make referrals to the appropriate agencies.

The service audited the number of and themes of safeguarding referrals to learn lessons and make improvements. We observed a safeguarding discussion at the daily MDT meeting. Patients told us they ‘felt safe’ at Rosebank House.

We reviewed the service safeguarding log for the period March 2026 to May 2026 which included the total number of safeguarding concerns raised, immediate action taken and outcomes. We saw this included working in partnership with other agencies.

Mental Capacity Act

Staff understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Health Act, Mental Capacity Act 2005 and the Children Acts 1989 and 2004 and they knew who to contact for advice including deprivation of liberty safeguards (DoLS).Staff completed training on the Mental Capacity Act, DoLS.  (93.1%) and the Mandatory Learning Disability Training (100%).

We found evidence of compliance with the Mental Health Act and Mental Capacity Act within patient care and management records. 

Staff took all practical steps to enable patients to make their own decisions, however, we noted 1 patient record, did not show the provider had reviewed their capacity to consent to taking off licence medication. This was discussed with the consultant and manager. Staff took action following this conversation, a medical review was arranged the same week to review this.

The service work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour.  Staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 9 care records and found people were actively involved in identifying and managing risks related to their care and support. Risk assessments reflected people's individual circumstances, preferences, and goals. Staff discussed potential risks with people and ensured they understood the measures in place to keep them safe while promoting their independence.

Care records showed people were encouraged to express their views about the support they received and how risks should be managed. Where appropriate, relatives and representatives were involved in these discussions to ensure decisions reflected people's wishes and best interests. This helped to ensure a person-centred approach to risk management. The 2025 patients survey 33% of patients agreed they were involved in their care and treatment. However, patients we spoke to told us they were involved in their care plan. 

People were supported to take positive risks that enhanced their quality of life and maintained their independence. Records demonstrated that staff balanced safety considerations with people's rights to make choices about their daily lives. This approach reduced unnecessary restrictions while helping people achieve outcomes that were important to them.

Risk assessments contained clear and detailed guidance for staff on how to support people safely and consistently. 

Information was tailored to individual needs and included actions to reduce identified risks. Staff told us they understood the risks associated with people's care and how to support them effectively.

We saw evidence that risks were regularly reviewed and updated when people's needs or circumstances changed. Reviews involved the person wherever possible and considered whether existing control measures remained appropriate. This ensured care and support continued to meet people's needs safely.

The service managed security and risk items well, there was a list of high risk and restricted items and barred items including drugs and alcohol. There was a poster at reception which displayed the list of banned and restricted items.

We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff completed and regularly updated environment risk assessment including, ligature risk assessments for all internal and external areas.

The service ensured that people who had mobility issues could access the service. The service had two floors with a lift to access the floors. 

The service complied with sexual safety guidance on mental health wards. For example, bedrooms were single occupancy, lockable and with en-suite facilities. At the time of the assessment, we observed that female patients were on the ground floor while the male patients were on the first floor.

All bedrooms were single occupancy, patient told us they felt safe at Rosebank and they can personalise their bedroom.

The environment was generally clean and well maintained, with a lift available for patients with mobility needs. The clinic room was secure, clean and tidy. The clinic room had all the required equipment to provide care.

We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

The evidence showed a good standard. The service 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.

The service was operating with temporary consultant medical cover as the permanent consultant in post at the time of inspection was on long term leave. The business continuity plan did not set out arrangements for maintaining consultant cover during extended periods of absence, which could impact service continuity.

Managers calculated the number and grade of nurses and healthcare assistants required for each shift, using the organisation’s staffing ladder.  Rosebank House operated a 2-shift system, with 2 nurses and 3 support workers on shift during the day and, 1 nurse and 3 support workers at night. When necessary, managers deployed bank and agency staff to maintain safe staffing levels. 

The service ensured that patients had regular one to one time with their named nurse. Patients we spoke with knew who their named staff members were and told us they met with them regularly to discuss their care and treatment.

Managers ensured that there was sufficient cover arrangement for medical and nursing staff including on weekends and out of hours.

Staff were experienced and had the right skills and knowledge to meet the needs of the patient group. Staff had received and were up to date with all mandatory training. The training was appropriate for their roles.  The service trained staff to support people with behaviours that challenge, this equipped staff to work with patients to manage risks for example, Safe and Supportive Observations and Engagement and Safe and Therapeutic Management of Violence and Aggression. At the time of the inspection the training compliance rate was 96.2% and 95.2% respectively. 

Managers provided staff with a comprehensive induction appropriate to their role. The service had an established induction programme for all staff, including permanent, locum and agency staff, to ensure they were equipped with the knowledge and skills required to work safely and effectively. Records showed that induction compliance for locum and permanent staff improved from 89.7% in July 2025 to 100% in May 2026.

Managers provided staff with regular supervision to support effective care, encourage reflection and learning from practice, and promote staff wellbeing and professional development. Staff performance was reviewed through appraisals. At the time of inspection, supervision compliance was 100%, and 88% of staff had received an annual appraisal up to May 2026. These arrangements supported staff to maintain and develop their knowledge, skills and competence in line with their roles and responsibilities.

Since the last inspection the service is now fully established, At the time of inspection, occupational therapist, psychologist and occupational therapist assistant were all in post.

We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

The evidence showed a good standard.  The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. The service documented clinic room and fridge temperatures daily and these were regularly audited. All staff had infection prevention control training, there was 100% compliant on inspection. It was noted in the March 2026 clinical governance meeting minutes, the importance of infection prevention control to be included in locum staff induction.

We reviewed cleaning records and these were fully completed, audited daily and we saw evidence that any actions arising from cleaning audits were taken. We observed all areas were clean, tidy and kept well-maintained.

The service completed monthly infection, prevention and control audit, which feed into clinical governance. 

The environment was generally clean and well maintained. The clinic room was secure, clean and tidy. The clinic room had all the required equipment to provide care.

We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen. 

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

Patients received their medicines safely. Patients’ physical health was monitored alongside their medicines. Staff completed observations, blood tests and monitoring for long term conditions. Patients were encouraged to self-administer medicines. However, for patients who self-administer medication, assessment was not carried out to determine the patient’s ability to self-administer medicines safely, identify any potential difficulties, and resolve any concerns. This meant that there was a risk patients may not take their medicines safely and effectively.

Patients were prescribed medicines to be administered on a when required basis for health conditions such as pain and anxiety. There were protocols in place to help staff administer these medicines consistently. 

Where people were prescribed high risk medicines such as clozapine, these were reviewed and monitored in line with national guidelines. The service had a visiting pharmacist who was part of the MDT and carried out medication and prescription audits. They also supported the team with reviewing prescribed medication to ensure they were safe and within recommended guidelines.

Medicines including controlled drugs were stored securely and at appropriate temperatures. 

While the service had emergency medicines such as Naloxone in stock and regularly checked.  However crucial medicines which was required for reversing the effect of a rapid tranquilisation such as flumazenil was not available.  The provider had not carried out a risk assessment to establish the reason for not keeping this medicine in stock. There is a risk that patients would not have access to this emergency medication if needed.