Rosebank Care Home

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 changed to requires improvement. This meant people were not always safe and protected from avoidable harm. The provider was in breach of the legal regulation in relation to the need for consent.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

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 did not always ensure people were supported in the least restrictive way possible. The doors to peoples’ bedrooms were continuously locked from the outside to prevent a number of people with symptoms of dementia from wandering into other peoples’ bedrooms. The provider failed to explore less restrictive options such as working with people individually to manage their symptoms of dementia. This meant all people who used the service had access to their bedrooms restricted. Where peoples’ ability to make decisions were assessed, the process had not always been robust. This meant we could not be assured the provider was working in line with the mental capacity act. Where people needed to be deprived of their liberties, there were systems in place to monitor DoLS (Deprivation of Liberty Safeguards) applications and authorisations to ensure conditions were met, and staff made the appropriate DoLS applications where people needed to be deprived of their liberty for their safety.

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. Staff knew how to protect people from abuse and who they would report any concerns to both internally and externally. People told us they felt safe using the service. One person said, “I feel safe here- everything makes me feel safe.”

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. Staff knew people very well and knew how to support individuals who were showing signs of distress. People and their relatives told us they were involved in their care planning and felt supported by staff. One relative told us, “We discussed the care plan at the beginning. Since then, I have had a form to complete a life history, so they are able to talk to [Family member] about their past.”

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

The provider did not always ensure staff were up to date with training. They did not always ensure staff received regular supervisions in line with the provider’s policy. This meant staff were not always provided with the necessary training and support to carry out their roles. There were sufficient staff to meet peoples’ needs. The provider ensured they were overstaffed by 12 hours daily to mitigate potential unexpected leave and provide extra staff to support people. People and their relatives told us they felt there were enough staff, and staff were kind and caring. Comments included, “Staff get to know people. One of the reasons we chose the home was the staff” and “They look after [family member] very well. We have never had to raise any concerns. As soon as I walked in, I knew everything was good. It had a lovely feeling.”

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, well-cared for, and free from the spread of infection throughout. Robust cleaning schedules were in place and regularly reviewed by staff and the management team. Peoples’ rooms were clean with freshly laundered bedclothing. One relative told us, “The home is always clean. If there are any accidents this is always cleaned up promptly. My [Family member] room is always immaculate.”

The staff were polite, gained consent, and recorded the administration of medicines on the electronic medicines administration record (MAR). Some people were prescribed medicines for pain relief and constipation to be taken on a when-required (PRN) basis. Guidance in the form of PRN protocols were in place to help staff give these medicines consistently. Person-centred care plans for medicines were in place. Care plans were in place to support people with their health needs. However, for people who experienced seizures, although care plans were in place, these did not have information about when staff members should be contacting emergency services.

Staff were trained in medicines administration and had competency assessments completed. Staff told us they supported people and clinical healthcare professionals so their medicines were reviewed periodically.

Medicines including controlled drugs were stored securely and at appropriate temperatures. However, the staff did not always record the medicine’s refrigerator temperatures as per policy. Medicines policies were in place. The process of ordering medicines was safe and effective, there was adequate stock of prescribed medicines. Regular medicines audits were carried out to identify gaps and make improvements. There was a process in place to report and investigate incidents. There was a process in place to receive and act on medicine alerts.