Rosebank Lodge

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment, the rating has remained requires improvement. This meant the service management and leadership was still inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The service was in breach of legal regulation in relation to the service not being consistently managed and the effectiveness of how the provider operated their governance system which had failed to pick up and/or address a number of issues we identified at this assessment.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The new managers were visible in the service, approachable and took a genuine interest in what people, staff, family and other professionals had to say. Staff felt respected, supported and valued by the managers, although most expressed being unhappy with the high turnover of managers they continued to experience at the care home. The new managers were receptive to challenge and welcomed fresh perspectives.

Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. The service has not be consistently managed. This was because the service remained without a registered manager and a deputy manager and continued to experience higher than expected rates of management turnover. Since our last inspection, the service has been without a registered manager for most of that time and has been heavily reliant of various temporary and often absent acting managers to be in day-to-day charge of the care home. This was identified as an issue at their previous inspection. Relatives expressed being dissatisfied with the services constantly changing managers. A relative told us, “Too many changes of managers. Just when you think you’re getting somewhere with a manager and building a good understanding and relationship with them, they up and leave.” An external community care professional added, “The service still hasn’t got a permanent registered manager in post who can provide consistent oversight and stable leadership, which the service has lacked for some time now and is crying out for.” We discussed this ongoing management issue with the provider at the time of our assessment and they took immediate action to restructure the services entire management team. This included the appointment of a new and suitably competent home manager who is in the process of applying to register with us and a new deputy manager. We will closely monitor how the provider achieves their stated aim of having the care home consistently managed by a suitably competent management team, including having a manager in day-to-day charge registered with us.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Feedback from people living in the care home, their relatives and staff was sought formally and informally, and used to develop the service. For example, the provider routinely used care plan reviews, team meetings, and stakeholder satisfaction surveys to gather people’s views about the care home.

The service valued diversity in their workforce. The staff team were representative of the local community and also reflected the diverse mix of people using the service. Staff told us there views were respected by managers and they felt valued. A staff member said, “I like working here. We work well together.”

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The providers established quality and safety monitoring systems were not always operated effectively. This was because they had failed to pick up and/or take appropriate action to address several new issues we identified at this assessment. This included issues we found in relation to the illegal use of unwarranted restrictive practices, insufficiently detailed and sometimes out of date risk assessments and management plans, staff not always suitably trained and supported, insufficient opportunities for people to engage in meaningful activities that reflected their social interests and medicines not always safely managed. However, the provider had developed an improvement plan for the care home based on a comprehensive internal audit they conducted in August 2024. Managers understood their responsibilities in relation to their regulatory requirements around notifiable incidents. Our records told us that appropriate, timely notifications were made to the CQC. We saw the service's previous CQC inspection report, which was clearly displayed in the care home and was easy to access on the provider's website. The display of the ratings is a legal requirement, to inform people, those seeking information about the service and visitors of our judgments.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement. The provider worked in partnership with various community health and social care professionals and external agencies including, local authorities, GPs, social workers, speech and language therapists, and the CQC. Managers told us they regularly consulted these external bodies and professionals, welcomed their views and advice, and shared best practice ideas with the whole staff team.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. The service did not always have a proactive culture of continuous learning and improvement. This was because the service was inconsistently managed by a constantly changing management team who had failed to always focus on continuous learning and improvement. We found opportunities to continuously learn lessons and improve the service were still being missed, especially when things had gone wrong. For example, the unnecessary and disproportionate use of restrictive practices. This was because the service continued to experience higher than expected rates of management turnover and remained without a registered manager in day-to-day charge of the care home who would be best placed to focus on continuous learning and improvement.