Rose Tree 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

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 good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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 identify and embed good practice.

Staff said they were supported to speak up, and improvements were made following feedback. One staff member told us, “We talk about what went wrong and how to make it better next time.”

Policies such as Duty of Candour were in place and up to date, promoting openness and transparency.

The staff worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

Staff worked with professionals, including GP’s and community matrons, to ensure continuity of care. Professionals confirmed communication was clear and staff followed advice consistently.

Relatives told us they were involved in planning and felt reassured during hospital discharges and changes in care. A relative said, “They kept us informed when [person] went into hospital and made sure everything was ready when they came back."

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

Staff understood safeguarding procedures and had completed relevant training. People and relatives said they felt safe and knew who to speak to if they had concerns. One person told us, “I feel safe here; staff would help me if something was wrong.”

Records showed safeguarding referrals were made appropriately and monitored, with no evidence of closed cultures.

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). Staff were working within the principles of the MCA and managed DoLS appropriately.

The provider 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.

Risk assessments were person-centred and reviewed regularly. Staff supported positive risk-taking, and people and relatives were involved in decisions about safety. One person told us, “They talk to me about my care and options to make choices – it’s really rather good.”

Observations showed staff acted promptly to reduce risks while respecting people’s choices.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Premises and equipment checks were regularly completed. Window restrictors and radiator covers were in place which reduced the risk of harm. Minor maintenance issues identified during the inspection, such as handrails needing to be painted, and empty Danicentre’s for the dispensing of aprons and gloves were addressed immediately.

The provider made sure there were enough skilled and experienced staff to meet people’s needs.

Safe recruitment procedures were in place.

Staff told us they felt supported, and morale had improved following recent management changes. Observations confirmed staff were attentive and responsive. One staff member said, “We have enough staff on shift, and we work well together."

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The home was clean and hygienic, with no malodours. Infection, prevention and control (IPC) audits were completed, and staff had attended training in infection control and the use of Personal protective equipment (PPE). People and relatives confirmed the home was always clean. A person said, “They keep everything spotless."

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

Medicines were administered by trained staff and audits were in place. Improvements were needed to ensure best practice. PRN (as required medicine) protocols were not always detailed and body maps for topical medicines (creams) were incomplete. Storage of returned medicines was not always secure. There was no evidence anyone had come to any harm. Tamper-proof containers were introduced during the inspection to ensure safe storage of medicines. Audits had identified gaps in PRN protocols and body maps; however, actions to address this had rolled on for several months.

People told us they received their medicines on time.