Red Rose Care Community

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• 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 to requires improvements. 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 people’s safe care and treatment.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons learnt had not always been completed from incidents, accidents, or complaints. This meant people were at risk of reoccurrence of incidents. This placed people at continued risk of harm. Where some learning had been completed this had not always been shared with whole staff team to ensure the learning could be put into practice. This meant there was not a safe or effective learning culture for staff to reduce the possibility of further incidents.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Health partners told us improvements had been made over the last year; however, people’s safety was not always managed. They raised concerns around staff not always identifying and managing people’s health deterioration and staff had not always called emergency services when required. This meant people were at risk of harm due to not have timely transitions to other services such as hospital. Care plans were not always accurate or detailed therefore there was a risk of incorrect information being shared between health services. This placed people at risk of not having their known care or health needs met. There was a new admission process in place to obtain people’s views regarding their care and support needs. A relative told us, “We went through a care plan when [family member] was admitted but I’ve not had any more involvement."

Safeguarding incidents had been recorded and escalated by staff to management when required. The registered manager reported safeguarding incidents to appropriate stakeholders such as the local authority safeguarding team. The provider had a safeguarding policy in place that provided staff with clear guidance on what they should do if they identified concerns. Staff had completed safeguarding training. Some people at the service were subject to a Deprivation of Liberty Safeguard (DoLs), this is where the person cannot make decisions about their care and treatment. So restrictive care arrangements are legally authorised in the person’s best interest. The provider followed this process in line with best practice guidance. This meant people who lacked capacity had decisions made lawfully in their best interest.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. We found staff did not have clear guidance in place to ensure people were supported in a safe way and according to their needs. For example, a person who had been identified as a high risk of falls did not have a risk assessment in place to ensure staff had clear guidance on how to manage the risk. Another person was living with diabetes, and we found there was not a person-centred risk assessment in place for staff to follow on how to safely support the person with their diabetes. This meant staff had no guidance in how to support the person with their health condition or recognise if there were changes in their normal condition.

Furthermore, a person who require wound management had discrepancies throughout their care plan, including the stage of skin damage and the level of care required. The lack of risk assessments and care plans meant staff had no guidance or accurate guidance to ensure they could support people safely.

The provider told us, “Red Rose is in the middle of transition from a paper-based system to an electronic care system. This is taking a huge amount of time and work to complete.”

The provider did not always 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

Health and safety checks had been completed. However, actions that had been identified had not always been completed in the required timeframes. For example, the provider had an external fire risk assessment carried out February 2025 which identified high risk action and stated these should be completed within 1 month, however the action was still outstanding at this assessment. The provider had arranged for this action to be completed before our visit and told us they worked with the local fire service. Furthermore, a legionella risk assessment had been carried out inJuly 2025, but the report was not received by the provider until October 2025, which identified a number of required actions. Many of the actions were classified as medium and high risks However, the providers action plan did not always ensure these actions would be completed within the require timeframe stated within the risk assessment. The provider had provided us with additional information after our onsite visit showing some actions had been completed and told us all the actions will be completed by 31 December 2025. Not completing health and safety actions in appropriate timeframes places people at potential risk of harm. We observed the home was secure as front doors required a code to gain access. Equipment that was in use to support people with mobility or transferring had been checked in line with best practice guidance.

The provider did not always make sure there were enough qualified, skilled and experienced staff. The provider had used a staffing calculator to determine staffing levels in line with people’s care needs. However, we observed staff we not always deployed safely. For example, we observed for a short time period there was no staff available to support people living with dementia who were showing signs of distress. This placed people at risk of avoidable harm. Most of the people and relatives we had spoken with told us there was not always enough staff. One relative told us, “They’re understaffed all the time, they’ve got so much to do and juggle. They can’t care as well as they’d like to care.” We found staff training had not always been completed. For example, staff had not completed anxiety training despite them supporting people with this. The provider was receptive to our feedback and shared an action plan that showed all staff training gaps would be completed by 21 November 2025. The registered manager ensured staff received effective support, supervision and development. Staff had regular one to one supervision and staff had 2 appraisals a year. This meant there was a process in place for staff to discuss their development. Staff had been recruited safely and completed an induction.

The provider assessed and managed the risk of infection. However, we found staff did not always follow the guidance. We observed staff did not always wear Personal Protective Equipment (PPE) such as gloves and aprons when supporting people with eating and drinking. PPE is essential for preventing the spread of infectious diseases from one person to another. This placed people at risk of cross contamination and infection. Staff had completed infection prevention and control training. The provider had a clear policy and procedure in place to manage infection outbreaks. We observed and people told us the home was clean. Domestic staff were visible and carrying out tasks, when spillages had occurred these were cleared up quickly and effectively.

Medicines were not always managed safety. People did not always receive their prescribed medicines on time. We found a person who required time-specific medicines often received these late. A person told us, “My [time-specific medicine] is late regularly, and they [nurses] tell me it’s because they were busy dealing with an emergency downstairs.” We observed this person’s medicine was not administered on time during our onsite assessment. This placed people at risk of avoidable symptoms because not taking time-specific (or time-critical) medicines on time can lead toaloss of therapeutic effect. People told us staff left their medicines with them to take with they are ready. One person told us, “I have tablet’s a few times a day and they’ll [staff] put them in a pot for me to take. Sometimes they [staff] leave them with me and will come back; I turn the pot over when I’ve had them.” This is unsafe practice and not line with national guidance as staff could not be certain people had taken these medicines and could be at risk of harm from not taking their medicines. The management team had taken immediate action after our feedback and introduced management spot checks and for all staff to re-read their medicine policy as a refresher to ensure safe practices are followed. Some people at the home were prescribed controlled drugs. These are subject to enhanced restrictions due to the addictive nature of these medicines. We saw staff had followed national legal requirements by storing these medicines in an extra secure place.