During an assessment under our new approach
About the service Rosewood Care Home is a care home which provides accommodation and nursing or personal care to people in a purpose-built building. Who the service is for The service supports up to 8 people with a learning disability or physical disability and people over or under the age of 65 years old. At the time of our assessment, the service was providing care to 5 people. We assessed the service against ‘Right support, right care, right culture’ (RSRCRC) guidance to make judgements about whether the provider guaranteed autistic people and people with a learning disability respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. We carried out this assessment on 1 October and 5 October 2026. This service was previously rated as good. We carried out this assessment to confirm whether the rating of good remains accurate. This report does not provide detailed information on areas where we found practice continues to meet a good standard. Instead, our findings focus on any areas where the service needs to improve or where we found exceptional practice. We found the provider was not always following best practices in relation to medicines. This included the storage of people’s prescribed thickening agent in the kitchen, two staff not always signing people’s medicine administration record where handwritten instructions were written and a lack of evidence of staff taking action when the temperature of the medicines room rose above the recommended temperature. We reported these shortfalls to the registered manager who worked to address the shortfalls immediately. Some staff said there were not always enough of them on duty. We heard, “We have our challenges. Sometimes it can be difficult. Although at no time would we put people’s safety at risk” and “We are short staffed. It can be 2 or 3 times a week.” Yet they said there was limited impact to people telling us, “We will always provide all the care people need. It might be only if there was no one to drive the van.” The registered manager told us, “I am constantly recruiting” and our review of the rotas showed there were occasions when there were less than the 5 staff we were told should be on duty, but this was not happening frequently. The registered provider spoke with us following our visit to highlight their plans for recruiting more staff able to drive the home vehicle. Additionally, people were not funded for 1:1 care and as such where additional staffing was provided to support people safely, this was funded from the providers own resources. On the other hand staff helped to ensure people were safe. They administered people’s medicines in line with the prescription information and staff ensured people had their food served in the right consistency to reduce the risk of them choking. The registered manager told us, “The speech and language therapy team came to do the texture modification training with all staff.” Where other risks had been identified for people, such as the risk of an epileptic seizure staff had drawn up detailed guidance on potential triggers for a seizure and what action staff should take in response. A staff member told us, “Someone had a seizure this morning and we were all there to help. It is not only the senior staff who can administer emergency medicines, we encourage all staff to learn as it helps ensure that all staff know what to do.” 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 and management worked within the MCA. DoLS authorisations were appropriately applied for and overseen. People were not subject to unlawful or excessive restrictions they had choice, control and freedom over their lives. Where restrictive practices were being used, such as lap belts in wheelchairs, the locked front doors and in-bedroom epilepsy monitoring, capacity assessments and best interests decisions had taken place. The registered manager told us, “We don’t assume they lack capacity. We still want them to be part of every decision made.” A staff member said, “The MCA is about whether they have capacity to make choices and decisions and people making the right decisions in their best interests. We would always assume that they have capacity in the first instance.” Staff understood their role in protecting people from the risk of abuse. A staff member told us, “If I saw something (such as poor moving and handling of a service user) I would go and report it and if I thought it needed to go further I would go down the necessary lines. We also have the phone numbers, etc. in the office.” The environment in which people lived was checked for its safety. This included fire equipment, the cleanliness and the maintenance. Where issues arose the registered manager raised these with the provider’s estates team who would address them. Staff received induction, mentoring and shadowing opportunities when they started at the service as well as regular supervision where they had the opportunity to meet with their line manager on a one-to-one basis to discuss their role and any training requirements. Staff worked with external professional agencies such as the district nursing team, occupational therapists and physiotherapists to help ensure people had the most suitable equipment in place to support their health needs. This included ceiling track hoists and specialist beds and through staff input, people’s lives improved and so did their wellbeing. The registered manager also told us, “We use a (physical deterioration and escalation tool) to reduce the need for people going into hospital.” A staff member said, “We care for the service users very well. It is rarely anyone has a pressure sore (despite everyone being a wheelchair user). If there is any sign of redness, we treat it.” Staff worked with people and family members to develop social stories, pictorial guidance and communication charts to help people express their needs. It was evident from spending time with people and staff that staff knew people extremely well and they had developed a detailed understanding of how people communicated. A staff member told us, “People are unable to do anything for themselves. You have to be their eyes and their ears.” The registered manager used the provider’s governance systems to monitor the service for its quality, acting on any shortfalls identified. This included where a storeroom door was found not to shut properly and this was escalated to the estates team. The provider also completed their own audits. However, neither of these review systems had identified the shortfalls with medicines practices. The registered manager had a passion and drive to move the service forward. They told us, “I have my own set of improvements that I want to happen. I discuss these through my own supervision. My vision is for them (people) to retain their health and for us to support them to move past the clinical bit and get out into the community more.” Staff told us they felt supported and were happy working at the service. We heard, “My colleagues are very supportive and caring. It’s a brilliant staff team. [Registered manager] notices and she encourages you. She doesn’t hold back.”