Rose Lodge

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.

We found the provider was in breach of the legal regulation relating to infection control, medicine management and good governance.

This service scored 56 (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.

The provider had systems in place for reporting, recording and investigating accidents and incidents. These were regularly monitored and reviewed to identify patterns and trends. The provider and registered manager understood their responsibility under the duty of candour. Lessons learned were shared with staff to improve practice and reduce the risk of recurrence. A staff member told us, “Once an incident occurs, it’s reported. Afterward, we usually have a debrief or handover discussion so we can learn from it and put measures in place to prevent it happening again.”

The registered manager 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.

Systems were in place to ensure people transitioned to the service in a safe manner and there was continuity of care. Before people moved into the home, an assessment of their needs was completed to ensure the service could meet their care and support requirements. People, relatives and healthcare professionals were involved in all aspects of care planning and reviews. A business continuity plan was in place so people would continue to receive safe and effective care in emergency situations.

Staff collaborated effectively with healthcare professionals to support people’s access to healthcare, helping them maintain their overall well-being. Most staff described care plans as ‘detailed’, although some staff told us they could benefit from further updates when people returned from hospital. One person told us, “I have my feet done, got new glasses recently and the GP comes if I’m unwell.” A relative said, ‘[Name] has seen the Chiropodist, and they can see the nurse practitioner if needed.”

The provider worked with people, healthcare and social care 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 with the local authority.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that staff ensured Deprivation of Liberty Safeguard (DoLS) authorisations were applied for when needed and any conditions were followed.

People were supported by staff who had the knowledge, training and confidence to recognise safeguarding concerns and take appropriate action to protect them from the risk of harm or abuse. A staff member told us, “Safeguarding, whistleblower policies and regular training are in place to ensure I protect residents from any form of harm and abuse.” A healthcare professional said, “Staff are responsive to highlighting issues and concerns.”

Staff worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff knew people well and worked with them, and their relatives/advocates to meet their needs in a safe and supportive manner. Risk assessments were in place and assisted staff to identify how to mitigate risks. Staff demonstrated a proportionate approach to risk that respected the choices people made about their care. A staff member told us, “Anyone that has capacity can make their own choices even if they are not good for them.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, and facilities supported the delivery of safe care.

We found not all portable electrical appliances had been tested to ensure they were safe for people to use. Maintenance records were not always accurately completed or sufficiently detailed. For example, we were told documents titled ‘nurse call systems checks’ also incorporated testing of ‘people’s sensor equipment’. The sensor equipment was not recorded.

We found window restrictors in the building were worn, damaged and in need of replacement, presenting a risk to people’s safety. Emergency pull cords were shortened and tied up in some communal shower/bathrooms. As a result, people may be unable to summon assistance in the event of an emergency.

Communal areas and bedrooms would benefit from redecoration. Some lounge and dining room furniture needed to be replaced. The provider had purchased new furniture. They sent us information to confirm this programme of refurbishment was ongoing. We were assured action was being taken in a timely fashion to make the improvements.

Staff reported concerns about the availability, reliability and the maintenance of equipment used to support people’s mobility. Comments included “stand aids and hoists are absolutely rubbish”, “batteries for hoists are never charged or are broken” and “we had one stand aid for all floors for many weeks” and “we start our shift looking for equipment that works”. We raised this with the registered manager, for them to address.

Premises and equipment safety audits and checks were routinely completed. However, these had not identified the concerns raised during this assessment. Staff received appropriate training to ensure they could use equipment safely when delivering care. Fire safety was well managed. The premises were accessible for those people requiring reasonable adjustments.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The provider and registered manager followed safe and effective recruitment practices. Staff understood their roles and responsibility. However, they shared mixed views about their induction experiences. Comments included, “two days, then left to get on with it”, “good but mostly e-learning” and “inductions are much better now.” A social care professional told us, “Staff should have more robust care inductions.”

Staff completed a range of mandatory training which did not include, oral health and end of life care. Records showed staff did not always receive condition-specific training, such as for diabetes and Parkinson's disease. As a result, staff may be unable to respond effectively to people’s specific needs. Some staff felt they would benefit from more ‘practical training’ not just e-learning.

Staffing levels were regularly reviewed. However, people and relatives told us the home was often short staffed. A person told us, “They are a bit short staffed.” A relative said, “They are always short staffed.” Feedback from staff regarding staffing levels and deployment was mixed. Some staff felt there were ‘enough staff’, whilst others identified areas for improvement and reported the working environment did not always encourage effective teamwork. Comments included, “staff regularly leave the floor for smoke breaks”, “seniors shouldn’t be counted as carers on the floor due to care plan and medicine duties” and “we never have enough staff, the floors go short on a regular basis.” We saw staff were visible throughout the day but occasionally could be task focused.

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

Systems and processes for the prevention and control of infection were ineffective. Equipment and areas in the home were dirty including, communal rooms, shower/bathrooms and the medicine treatment room. Hand washing facilities lacked soap, sanitizer, paper towels and wastepaper bins. Chairs in communal lounges were stained. Cobwebs and dead insects were noted on windows. Dirty laundry and clinical waste were not always managed effectively.

Daily, weekly and periodic cleaning schedules showed cleaning was routinely missed and did not provide enough detail of what cleaning tasks staff were expected to complete. On some days no domestic staff were on duty. Staff described the cleanliness in the home as an “area for improvement” and “it could be cleaner”. Relative’s comments included, “no one cleaned it up” and “it was like that for 4 days before it was cleaned”.

Staff did not routinely follow good food hygiene practice. For example, staff did not cover food when served to people in their bedrooms. There was no evidence all staff had read the provider’s infection prevention and control policy.

The provider did not make sure medicines and treatments were managed safely and met people’s needs. Systems and processes for the management of medicines were ineffective.

The medicines treatment room was not clean and lacked suitable hand washing facilities. It contained unclean equipment such as medicine trollies, tablet cutters and an in-use inhaler. People’s nasal sprays, topical medicines and eye drops did not always contain dates of opening. This meant the medicine may no longer be effective or safe to use. Some people’s in-use medicines and unopened creams were stored in 2 unlocked cupboards due to storage capacity issues. Loose tablets were found in 2 envelopes in a medicine trolley. Four sharps bins, used for the disposal of medical needles and syringes, were full and needed to be discarded safely. A person’s time sensitive medicines were not given at the time stated. This delay could worsen the person’s symptoms.

Some people were prescribed medicines to be taken on a ‘when required’ basis or with a variable dose. The effectiveness of these medicines was not always recorded. Some medicine stocks exceeded the recorded balances and totals of controlled drugs did not always tally between the electronic records and the controlled drugs book. There was no evidence all the staff responsible for the administration of medicines had read the provider’s medicine policy. Relatives and staff expressed mixed views about the timely administration of some medicines. The provider’s medicine audits had not identified all the issues we found. This was an area for improvement. We raised this with the provider for them to address.