Rosebank 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 provider had made improvements and is no longer in breach of regulation relating to safe care and treatment. The rating has changed to good. This meant people were now safe and protected from avoidable harm.

This service scored 75 (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 made improvements since our last inspection and was no longer in breach of regulations. People now received safe care from managers and staff who had developed a positive learning culture within the care home. This was because the service now had a stable team of suitably competent permanent managers in post which included a new service manager, deputy manager and head of area manager. These managers understood the importance of reporting safety concerns and learning lessons when things went wrong. Systems were in place to support staff to report and record safety concerns and events when they arose. Any safety concerns or incidents that did occur were investigated and any lessons learnt were shared with staff and used to continually improve the service and keep people safe.

The provider 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.

Managers gathered information about people’s individual needs and wishes, and risks to their safety, prior to them using the service. This information was used to develop person-centred care and risk management plans which were shared with staff to help them provide safe and appropriate care to people from the moment they started living at the home.

The provider worked with people 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.

The provider had made improvements since our last inspection and was no longer in breach of regulations. People were no longer deprived of their liberty unlawfully. Fob devices attached to people’s bedrooms doors which meant they locked automatically when they closed to prevent people entering these private spaces without the occupants’ permission had been removed. Managers had also reminded staff about their duty of care to minimise the use of restrictive interventions and to only use them as a last resort. We observed the kitchen door remained unlocked throughout our assessment. This enabled people to move freely around the care home and spent their time as they wished, with no unnecessary restrictions. A relative told us, “I’m not aware my [family member] is ever restricted in anyway at the home and I know all the automatic locking devices that were fitted to everyone’s bedroom doors were removed earlier this year [2025].” A member of staff added, “We have been constantly reminded that under no circumstances must anyone be locked in their bedroom or have their access to the kitchen restricted by keeping these doors locked on the grounds of safety. The practice was wrong then and we know better now. The same mistakes will not be repeated in the future.”

Managers and staff understood how to safeguard people. They knew how to recognise and report abuse and were able to articulate how they would spot signs if people were at risk of abuse or harm. A member of staff told us, “I would tell one of the managers straight away if I ever saw or heard about anyone, we support here being neglected or abused.” Managers made timely safeguarding referrals when required and worked with the relevant partners to ensure people were safeguarded from further risk. People told us they felt safe living in the care home and with the staff who supported them there. A relative said, “Yes, my [family member] is kept at the care home by staff.”

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.

The provider had made improvements since our last inspection and was no longer in breach of regulations. Systems were now in place to ensure risks to people were routinely assessed, monitored and reviewed. People’s care records contained current and sufficiently detailed information about potential risks to their safety and how these risks should be prevented or appropriately managed. For example, a risk management plan for a person identified as being at high risk of choking was now sufficiently detailed and easily accessible to staff. In addition, peoples risk assessment and management plans were now being reviewed at more frequent intervals and updated according to reflect any changes in people’s needs.

Managers and staff were fully aware of the potential risks people might face and the steps they needed to take to prevent or safely manage them. A member of staff told us, “Risk assessments and plans have improved because they are far more detailed and easier to follow and understand.” Another member of staff added, “I recently updated my positive behavioural support training, so I know what specific action I need to take to initially prevent such incidents happening in the first place or deescalate them if they do occur. It’s a different approach for each person we support.” People had positive behaviour support plans in place which ensured staff had access to all the relevant information and guidance they needed to prevent or appropriately manage incidents when people became distressed. Staff remained vigilant to people’s whereabouts and were visibly present throughout this assessment.

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

The provider had made improvements since our last inspection to the care homes environment. The interior of the care homes communal areas had all been redecorated and the environment made more ‘learning disability friendly’ with the reintroduction of a fully operational sensory room. The managers told us although the care homes refurbishment programme remained a work in progress most of the work was now complete. An action plan remained in place for all the bedrooms to be repainted in the colour the person who occupied them wished by mid-2026.

The premises were kept free of obstacles and hazards and all the internal bedroom doors and the kitchen remained unlocked throughout this assessment. This enabled people to move freely around the care home and spent their time as they wished, with no unnecessary restrictions. Managers assessed potential health and safety risks people might face and plans were in place to mitigate risks posed by the care homes environment. Safety systems and equipment were maintained and serviced at regular intervals, so that they remained in good order and safe for use. Staff understood the importance of maintaining a safe environment for people. Staff told us they had clear guidelines available to help them deal with emergencies, including individualised plans to evacuate people in the event of a fire.

The provider 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 provider had made improvements since our last inspection and was no longer in breach of regulations. Staff were now suitably trained and supervised to meet the needs of the people they supported. For example, all staff had now received up to date training in learning disability and autism awareness, moving and handling, the safe management of medicines, and safeguarding adults. A relative told us, “The staff know how to look after my [family member] and seem to be well-trained.” A member of staff added, “Training we receive has improved since the new managers were appointed. It’s always relevant and is now being refreshed at more regular intervals, so we can keep up to date with our working knowledge and skills.”

In addition, staff now received regular formal supervision meetings with their line managers. The new service manager had a time specific action plan in place and they confirmed all staffs’ overall work performance in the last 12 months was scheduled to be formally appraised by the end of 2025. This meant staff now had enough ongoing opportunities to reflect on their working practices and to identify any further training, learning or support they might need. A member of staff told us, “I do feel I get all the support I now need from the new managers. Supervision meetings with them is happening more often these days.”
 

Staffing levels matched the staff duty rota on the day of our site visit. Staffing levels were based on people’s needs and the number of 1:1 support they required to stay safe. Managers told us they had worked with one person’s funding authorities to review the staffing they needed and had secured additional staff support. Managers and staff were visibly present in the care home throughout this assessment and quick to provide people with assistance as and when required or requested. People told us the care home was adequately staffed. One person said, “Lots of staff work here who I like.” A relative added, “There’s always plenty of staff around whenever I visit which is pretty regularly.” There service had no staff vacancies at the time of this assessment.

Staff recruitment practices at the service remained safe. Managers undertook the necessary checks required on staff that applied to work at the service, to make sure they were suitable to support people.

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.

People lived in a clean, hygienic environment. Staff followed current best practice to reduce the risk of infections spreading. A relative told us, “The staff do a good job keeping the place clean and odour free. Much better than it used to be.” Staff were provided with relevant training to help them prevent and control the risk and spread of infection in the care home. They had access to resources and equipment to help them reduce infection risks and used this appropriately, which included adequate supplies of personal protective equipment (PPE). Managers undertook regular checks on staff’s infection prevention and control practices. Staff appropriately maintained cleaning and food safety records to provide a clear audit trail of measures taken to reduce infection risks at the service. The provider’s infection prevention, control, and food hygiene policies and procedures were current and reflected national guidance.

The provider made sure that medicines were safe and met people’s needs, capacities and preferences.

The provider had made improvements since our last inspection and was no longer in breach of regulations. The services medicines systems were now well-organised and safely managed. How medicines were managed had improved including, how they appropriately maintained medicines records and continuously assessed staff competency to safely manage medicines on behalf of the people they supported. Care plans contained detailed guidance for staff about how people needed and preferred their medicines to be administered. Sufficiently detailed protocols were now also in place to guide staff in relation to the safe administration of people prescribed medicines including, 'as required' medicines. Staff had also received up to date safe management of medicines training. Managers undertook regular spot checks and assessments of staff’s medicines handling practices, to reassure themselves that staff remained competent to safely manage medicines.

Medicines stocks, balances and records showed people consistently received their medicines as and when they should which people confirmed. A relative told us, “I think the staff manage my [family members] medicine well. I have never known any issues with that side of things.” There were regular audits of medicines at the service. Medicines were stored correctly in locked cabinets attached to the wall within each resident’s room. A recent independent external audit of the services medicines management identified no issues with the current arrangements.

The managers were working with people’s GP to review prescribing practices and where possible reduce the prescribing of psychotropic medicines in line with STOMP. STOMP isa national NHS England program to Stop The Over-medication of People with a learning disability, autism, or both, with psychotropic medicines.