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 rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. We found no evidence that people had been harmed however, the provider was in multiple breaches of legal regulations in relation to safeguarding, risk assessing and management, staff training and support, safe management of medicines and governance. This was because staff sometimes used unnecessary and disproportionate restrictive practices. Staff also needed to have easier access to more sufficiently detailed and up to date risk assessments and management plans to follow and ensure they knew how to prevent or safely manage any potential risks people they supported might face. Staff had not received all the relevant and most up to date training and formal support they required to meet people’s needs and keep them safe. Medicines were not always safely managed. We identified a number of recording errors and/or omissions on medicines administration records (MAR) sheets and staff did not always have access to sufficiently detailed instructions about when and how to administer people's prescribed medicines safely. A lack of stable management meant issues were not always picked up and addressed in a timely manner. Lessons were also not always learnt about how to continually improve the safely and quality of the care people using the service received.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People did not always receive consistently safe or a good standard of care from staff as the service did not have a proactive and positive culture of learning lessons when things went wrong. This was because the service continued to lack a stable management team. The care home remained without a registered manager and a deputy manager and continued to experience higher than expected rates of management turnover. In the past 2 years the service has only had one registered manager in post for less than 6 months, as well as multiple temporary acting managers in day-to-day charge of the care home. This lack of consistent management has led to the provider failing to identify and/or take appropriate action to learn lessons and resolve a number of new issues we found at this assessment. We discussed this ongoing issue with the new managers at the time of our assessment. They told us they had all just been appointed to oversee the day-to-day running of the care home. It was clear from their feedback they recognised the importance of learning lessons and continuous improvement to ensure they maintained high-quality, person-centred and safe care for people. For example, the care homes new manager showed us an improvement plan based on the findings of an internal audit they conducted in August 2024 that identified what needed improving and the action they needed to take to achieve this.

The service 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 planned and organised care and support with people, together with partners and relatives in ways that ensured continuity. Managers explained how they reviewed partner information and assessed prospective service users’ needs before deciding if the care home could safely meet those needs. These assessments were used as the bases to develop person-centred care plans for everyone who lived or stayed at the care home.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. People did not always receive consistently safe care and support from staff. This was because people had sometimes been deprived of their liberty unlawfully. Prior to this assessment we were informed about incidents whereby staff were locking people in their bedrooms who were unable to open the door independently. An external care professional told us, “I saw my [client’s name] was locked in their bedroom when I recently visited the care home as I witnessed staff unlock their bedroom door to deliver fresh laundry. There was no legal mechanism in place to allow the service to lock my client’s bedroom door like this.” A relative added, “My [family members] bedroom door locks automatically because of a fob device they have attached to the wall near their room, which is not right.” The negative comments described above notwithstanding, we found no evidence during this assessment that these restrictive practices continued to be used in the care home and people living there had been harmed. Managers and staff were aware of safeguarding reporting procedures. 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 not hesitate to tell the person in-charge if I saw anyone we support here being abused to neglected inside or outside the care home.” The service had several safeguarding investigations open at the time of our assessment.

The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People did not always receive consistent care and support from staff to manage risks associated with their health and wellbeing. This was because there was not always sufficiently detailed and up to date written guidance for staff to follow that made it clear what steps they needed to take to keep people safe. For example, a risk management plan for someone who was identified as being at high risk of choking was not always easily accessible to staff. In addition, risk management plans were not always being reviewed at regular intervals and up dated according to reflect any changes in people’s needs. This contradicted recognised best practice and the provider's own risk assessing and management policies and procedures. For example, a positive behavioural support and choking prevention and risk management plans in place both contained out of date guidance for staff to follow as neither had been reviewed for over 6 months.

The service did not always ensure adaptations and reasonable adjustments were made to the environment to meet people’s individual needs. While people said their family member or client was comfortable living at the care home, most felt the interior layout, décor and furnishings was in urgent need of improving. A relative told us, “I do think my [family member] is comfortable living at Rosebank Lodge, but I just wish the old sensory room was up and running again, so everyone could enjoy them. There’s so much room inside the house and the garden, it’s a travesty this space is not being utilised properly.” We saw the care home environment was not particularly ‘learning disability friendly.’ For example, the physical environment did not reflect or meet the sensory needs of the people who lived at the care home. We also found the care home’s physical environment, interior décor and furnishings were not always maintained to a good standard. For example, we identified damaged wallpaper, paint and furniture in the communal areas. We discussed these issues with the new managers at the time of our assessment who acknowledged the care home was well overdue refurbishing. It was positively noted an action plan was already in place for care homes environment to be improved within the next 6 months. Progress made by the provider to achieve its stated environment aims will be closely monitored by the CQC. Regular checks were completed by managers and staff to maintain the safety of the care homes physical environment. This included regular health and safety checks on the homes electoral, gas and water systems, and equipment used to support people, such as mobile hoists. The provider had an up to date fire risk assessments in place for the building and personal emergency evacuation plans [PEEPs] in place for everyone who lived at the care home.

The service did not always ensure staff were suitably competent, and skilled to meet the needs of the people they supported and do so safely. They also did not always make sure staff received effective support, supervision and development. Staff were not always suitably trained and supervised to safely meet the needs of the people using the service. Half the current staff team had not received all the relevant and most up to date training they were required to have to safely meet the needs of people they supported, such as learning disability awareness, moving and handling, the safe management of medicines, and safeguarding adults. A relative said, “The staff are really friendly and kind, but I don’t believe they’re all properly trained.” In addition, the provider failed to ensure staff always received effective support, supervision and development from their line managers. This was because staff had not attended regular formal supervision meetings in the last quarter and nor had any of their overall work performances been appraised in the last year. This contradicted recognised best practice and the providers own staff support procedures. Staff were visibly present throughout this assessment, providing people with the appropriate levels of care and support they needed. For example, We observed staff were vigilant when people were moving around the care home. Staffing levels in the care home matched the staff duty rota on the days we visited and we saw one-to-one staffing was in place for people assessed as requiring this level of staff support. People told us they were happy with staffing levels at the care home. A relative said, “There's always plenty of staff on duty whenever I visit my [family member].” The provider conducted thorough checks on staff that applied to work at the service to make sure they were fit to support vulnerable adults.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The care home looked and smelt clean throughout. Staff had received up to date infection control and food hygiene training people said this was reflected in their work practices. This included frequent washing of hands and using hand sanitizer gel. Staff told us they had access to adequate supplies of Personal Protective Equipment (PPE).

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We identified a number of recording errors and/or omissions on medicines administration records (MAR). This meant it was unclear if these medicines had been given on time or missed. There were no protocols in place to guide staff in relation to 'as required' medicines. This meant staff did not always have access to clear instructions about when and how to safely administer these medicines. In addition, not all staff authorised to manage medicines in the care home had received up to date safe management of medicines training or had their competency to continue doing so safely routinely assessed by managers and/or senior staff. Furthermore, it was not always clear from medicines records we looked at what medicines were prescribed to people and how staff should administer them. We discussed this medicines recording issues with the new managers at the time of our assessment who responded immediately. By the second day of our site visit we found the relevant MAR sheets had been reviewed with the relevant external health care professionals and these records now reflected peoples prescribed medicines and how staff were expected to administer them.