Rosebank House

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

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 Good. At this assessment the rating has remained 

Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

At our last assessment we rated well-led as good. At this assessment the rating has remained good. Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Governance processes operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected analysed data about outcomes and performance. They used this to identify improvements.

We have not awarded this service a score for Well-led.

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

Staff had a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

The evidence showed a good standard. The service 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 knew and understood the provider’s vision and values and how they were applied in the work of their team. The providers visions were kindness, integrity, teamwork and excellence, and staff demonstrated these in their day-to-day work. 

The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. 

Staff had the opportunity to contribute to discussions about the strategy for their service, and they were actively involved in shaping the service. Staff from the service were involved with peer review of other services. The regional expert by experience who represented the interests of the patients also supported the service development. 

Staff could explain how they were working to deliver high-quality care within the budgets available, for example, growing their own workforce. 

Staff have inclusive leaders at all levels who understand the context in which they deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

The evidence showed a good standard. The service 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.

Leaders and staff understood their roles, responsibilities and accountabilities and demonstrated the skills, knowledge and experience required to carry out their duties effectively. Leaders had a good understanding of the service and were able to clearly describe how teams worked together to deliver high-quality care and support. They spoke compassionately about patients and demonstrated a commitment to promoting positive outcomes.

Staff spoke positively about both local and senior leaders, describing them as approachable, accessible and supportive. Staff told us that senior leaders were visible within the service and engaged with both staff and patients.

The service also involved an Expert by Experience at a regional level, who attended governance and community meetings and met individually with patients to gather feedback about their experiences. Information obtained through these meetings was used to inform service development, quality improvement initiatives and governance processes.

The service created a positive culture where people feel that they can speak up and that their voice will be heard.

The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff said they knew how to raise a concern and felt comfortable to do so. They were aware of the service’s whistleblowing policy, and how to contact the freedom to speak up guardian. 

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. The service had a ‘you said, we did’ board that displayed actions taken. The service undertook patients and carers surveys to understand how they were meeting people’s needs, ‘patients said they know their feedback can be used to improve the service’, ‘A carer said they were aware of the planned carer event but was unable to attend’.

Managers had access to feedback from staff via surveys and they devised action plans to make improvements. Staff we spoke to said they ‘felt supported, have regular supervision, leaders are visible and they have access to training’. 

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff and leaders understood their roles and responsibilities under Equality Act 2010. 100% of staff had completed their mandatory diversity training. Staff felt their peers and managers treated them fairly and with respect.

There were mechanisms in place to protect staff from discrimination in the workplace in line with their diversity, equity and inclusion policy, zero tolerance policy and freedom to speak up policy. Staff were actively encouraged to complete incident reports for all racism at work and to report racist acts to the police. 

Staff reported that they could manage their job and responsibilities in a way that enabled healthy work-life balance. Staff we spoke with told us they could work flexibly where required. There were flexible working agreements in place to account for personal circumstances such as caring responsibilities and health issues. 

Staff and patients had access to activities and facilities that their cultural and or religious needs. For example, there was a quiet room which patients and staff could use for prayer and reflection if needed. If a patient required a specific meal because of their culture or religion, this could be provided by the service.

Staff and patients are addressed with respect and in the way they wished to.

The service have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate. 

The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We identified concerns where it was not clear how issues had been escalated, monitored or addressed through governance processes. These included the assessment of patients’ ability to self-administer medication safely, the review of consent for off-licence medication, and inconsistencies in the recording of Section 17 leave, signing patients in and out.

Although senior leaders were aware of some of these issues and told us they had been identified through governance processes, it was not always clear how concerns had been escalated or what actions had been taken to mitigate risk. Leaders described ongoing work to improve the Section 17 leave process to provide greater assurance of patient safety and were reviewing systems to ensure outstanding actions relating to consent, capacity and treatment decisions were identified and completed.

Further work was required to ensure governance arrangements were fully embedded and consistently effective in identifying, escalating and addressing concerns.

Managers had access to information to support them with their role. They reviewed monthly data that provided essential information on the performance of the service.

We reviewed examples of governance and staff meeting minutes. There were a clear framework and agenda to ensure that essential information, such as learning from incidents, complaints, and safeguarding referrals were discussed and shared with staff. There were patient representatives at the governance meetings.

Managers ensured staff routinely collected information and participated in clinical audits. There was a robust audit programme in place at both local and provider level including essential topics such as, care plans; enhanced observations; reducing restrictive practice and infection control, the results of which were shared with teams.

There was a robust audit programme in place. Staff participated in both local and provider wide clinical audit and quality improvement initiatives, topics included such as, record keeping. 

We saw that managers and staff had implemented actions from reviews of incidents, complaints and safeguarding alerts at the service level. We could see actions and lessons learnt from the incidents, complaints and safeguarding logs we reviewed as part of the inspection.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, generally worked well and helped to improve the quality of care. Information governance systems included confidentiality of patient records. Patient records were stored securely.

The service had plans in place for emergencies including business and major incident contingency plans. However, the plan did not demonstrate the cover arrangement when the consultant was unavailable for long periods to ensure that there was continuity of care. The Provider told us they are in the process of reviewing the senior medical cover.

The service has a clear environmentally friendly initiative green agenda, with posters displayed and the implementation for reducing single use plastic, we saw this discussed in the clinical governance meeting minutes.

Staff understand their duty to collaborate and work in partnership, so the services work seamlessly for people. they share information and learning with partners and collaborate for improvement.

The service worked well with community mental health teams, social workers, GPs and other local services to make sure people received joined-up care. Staff shared information appropriately and involved external professionals in care planning and reviews, helping people to achieve their recovery goals.

People were supported to be part of their local community and develop greater independence. Staff encouraged people to access volunteering, employment and social activities that matched their interests. People told us they felt supported to build confidence and maintain relationships outside the service.

The service had positive working relationships with families, carers and partner organisations. Staff worked together with others to plan for people's future needs and support successful moves towards more independent living. Leaders promoted a culture of partnership working, which helped people achieve positive outcomes.

Leaders engaged with external partners such as commissioners to keep them regularly updated and maintained relationships with the local authority. Managers said they had good working relationships with these services and, is engaging to further develop relationships with the local Integrated Care Board (ICB).

Managers and staff understood the arrangements for working with others, both internally and externally, to meet the needs of patients. They encouraged patients to access local organisations for social engagement for example, the library, sporting activities, and the cinema. 

The service focus on continuous learning, innovation and improvement across our organisation and the local system. They encourage creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The service had a positive culture of learning and improvement. Staff were encouraged to reflect on incidents, feedback and people's experiences to identify what worked well and where changes were needed. Lessons learned were shared with the team and used to improve the quality and safety of care.

The service conducted a quality improvement project to address the number of AWOL incidents, by reviewing individual length of time on unescorted leave. The implementation of the learning from this project was good experience and outcome for patients.

Leaders monitored the service through audits, quality checks and regular review of performance. Where issues were identified, action plans were put in place and progress was tracked. Staff told us they felt able to raise concerns and suggest improvements, and they felt their views were listened to.

The service looked for ways to develop and improve people's experiences and outcomes. We saw examples of quality improvement initiatives projects; the Occupational Therapist is conducting a quality improvement project looking at increasing patients’ attendance at activities.  These included for example, accessing the local community such as, sports and local day trips. Patient discussed the activity timetable and what could be improved at community meetings. 

Staff received training and opportunities to develop their skills, helping them provide effective support. Leaders demonstrated a commitment to continuous improvement and used feedback from people, relatives and partner organisations to help shape the service.

The patient representative with the regional expert by experience, supported the service with co production. The service recognised the importance of hearing what family and carers had to say and to have a space to talk to build and develop the service together.

Staff were given the time and support to consider opportunities for improvements and innovation. They had opportunities to feedback in meetings, supervision, and through a staff survey.

Staff participated in regional peer review, audits relevant to the service and learned from them.