Rosewood

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

This service scored 69 (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.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider worked with people and healthcare 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.

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

The provider did not always make sure there were enough qualified, skilled and experienced staff.

Staff told us there were times of staff shortage and although they said there was little impact to people it did mean on occasion people may not be able to participate in their external activities due to a lack of driver. Our review of staff rotas showed the occasional time when staffing levels were below the expected number, although this did not happen consistently, but the lack of potential regular drivers for the service meant people’s opportunity to living a consistent fulfilling life may be reduced. This was an area that the provider was working hard to address to help ensure people had sufficient opportunity to engage with the local area.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

Staff were not always following best practice in relation to medicines practices. We found people’s prescribed thickening agent stored on the worktop in the kitchen. Although people living at the service would not be able to ingest these inadvertently (as they were all wheelchair users), there was a possibility that new staff or visitors would have access to this medicine. By the time of our second visit to the service, these had been moved to a locked cupboard.

We also found the temperature of the medicines storage had exceeded safe levels on several occasions. Although the registered manager told us, “I am sure that the staff would have used the AC unit that I bought” there was no evidence to demonstrate this was the case and the high temperatures had not been raised with the registered manager. This meant staff could not be assured that people’s medicines had not be compromised.

People had individual medicine administration records (MAR). Although we saw these had been completed well, we did identify 1 gap where a medicine appeared not to have been dispensed. We also noted that handwritten prescription information was not double signed. This is especially important when transcribing or altering prescription information as it helps to prevent medicines errors.

Despite these areas which required action, people did receive the medicines they received and staff held PRN (as and when) protocols in place for medicines that people required only occasionally.