The Rosary Nursing 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

People felt safe at the home and looked comfortable and relaxed with staff who supported them. Staff knew how to recognise and report abuse and were confident anything they raised would be acted upon by the management team. Staff spoken with understood the principle of the Mental Capacity Act 2005. Where people had been assessed to lack the capacity to make specific decisions relevant others were consulted, however, this was not always recorded. There were sufficient staff who were well supported and had received training to meet people’s needs. Staff promoted people’s independence. We observed that people were supported to move freely around the home. When risks had been identified, care plans contained guidance for staff to ensure the risks were managed. However, we found some risk assessments required additional information to ensure all of the control measures in place were recorded. There were processes in place to learn from any complaints, incidents, or accidents.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There were processes in place to learn from any complaints, incidents, or accidents. The daily heads of departments meetings and staff meetings were used to share information. There were a range of audits in place that identified where any actions were needed or improvements required. Any actions identified were monitored through the service’s action plan.

Staff told us lessons learnt were shared amongst the team. One staff member told us, “We are made aware of the outcome, we are honest and transparent with management” [in response to any investigations into incidents]. Another staff member told us, “I am comfortable to raise any concerns.” The registered manager told us learning from incidents was shared amongst the team. The registered manager commented, “We talk about what went wrong, any improvements and go through any lessons learned.” The provider gave examples of how wider organisational learning was shared amongst the teams.

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.

Staff had received training in safeguarding. The registered manager had reported safeguarding concerns to the local authority and the CQC as required. Where people had been assessed to lack the capacity to make specific decisions relevant others, such as family members were consulted. However, this was not always recorded on the best interest form. We discussed this with the registered manager who told us they would ensure this was included on the best interest form. Where needed, appropriate applications were completed to authorise a person being deprived of their liberty.

People felt safe at the home and looked comfortable and relaxed with staff who supported them. One person told us, “It is safe”, another commented, “I do feel safe here.” Relatives told us they were happy with the care their loved ones received. One relative told us, “When I go, I feel I have left him in good hands.”

Staff knew how to recognise and report abuse. They said if they reported any concerns, they were confident that action would be taken. They said they would report to the registered manager or deputy manager who would see it as really important and take action. The registered manager was clear about their responsibilities to report and investigate any safeguarding issues. Staff spoken with knew understood the principle of the Mental Capacity Act 2005. They told us about the process of making decisions in people’s best interests, where people lacked the capacity to do so. Staff told us they involved families in this process and spoke with relevant professionals.

Staff were aware of people’s risks and the plans in place to reduce them. Staff confirmed risk assessments were up to date and reviewed regularly. The registered manager told us they supported people in a way that was not risk adverse. They understood the importance of people making decisions for themselves and staff supporting people in line with their wishes.

Risk assessments had been completed for areas such as falls, skin damage, malnutrition and choking. When risks had been identified, care plans provided guidance for staff. Some people had pressure relieving mattresses in place. We found some of the pressure relieving mattresses were not set at the correct setting. We discussed this registered manager who confirmed this was addressed during the assessment site visit. When people had been assessed as being at risk of falls, care plans detailed the steps staff should take to reduce the risks, such as ensuring any mobility aids were close by and supporting people when needed. Care plans contained guidance for staff around any health needs and associated risks. Records showed that when risks had been identified, staff supported people in line with care plan guidance. Risk assessments had been regularly reviewed, however there was not always evidence of anyone other than staff being involved in these reviews, for example, people and their relatives. Some of the risk assessments did not include all of the control measures that were in place.

During the assessment site visit we observed people being supported in line with their care plans and risk assessments.

People were supported to move freely around the home and there did not seem to be any unnecessary restrictions on people. People’s relatives confirmed risks were discussed with them and relevant information was shared.

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

Staff rotas were based on the dependency tool which was reviewed monthly. There was a consistent and stable staff team in place. Recent supervisions had been completed with staff concentrating on their well-being. Feedback was staff felt valued and respected. Staff received the training needed to meet people’s needs. Staff were encouraged to complete relevant qualifications and all staff were supported to complete the care certificate if they were new to care.

People told us there were enough staff available. One person told us, “There are always staff around.” Other comments from people included, “Yes, I am not rushed” and “I have a call bell here. Sometimes they do take a long time to come. They say they have been helping someone else who needs 2 carers.” A relative told us, “Yes there are enough staff, and they are very patient.”

We observed there were enough staff available to respond to people’s needs. Our observations of staff supporting people were positive, for example when using equipment to safely support people to transfer. People were observed to be supported by kind and caring staff.

Staff told us there were enough staff available to meet people’s needs. One staff member told us, “Yes, there's enough staff on duty, but some staff have been off sick lately. Staff come in for extra if they can, we use bank staff. We use no agency at the moment. The management team will help if they have time. I can ask [Name of registered manager] to help if needed.” Another staff member told us, “We are in a good place at the moment [staffing].” Staff said they worked well as a team. Staff were happy in their roles and felt well supported. They told us they received appropriate training and supervision. The registered manager confirmed they had a staffing dependency tool which was reviewed monthly. They confirmed they were currently fully staffed.

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.

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