Three Roses

This assessment was carried out because the provider was previously in breach of the legal regulation in relation to safe care and treatment, fit and proper person employed and good governance. Improvements were found at this assessment, and the provider was no longer in breach of regulations.

Since the last assessment, governance arrangements had been strengthened. The provider had implemented a range of quality assurance systems and audits which provided improved oversight of the service. The registered manager now demonstrated a good understanding of their regulatory responsibilities and had developed systems to monitor quality, identify areas for improvement and drive change. Governance processes were strengthened through regular reviews completed by an external quality assurance team, which supported continuous improvement.

However, further work was needed to ensure governance systems were consistently effective in identifying, monitoring and addressing risks across the service. For example, although recruitment practices had improved since the last assessment, some minor areas for improvement remained particularly in relation to exploring gaps in employment history for new staff. We also identified some shortfalls in medicines management; however, there was no evidence that people had experienced harm as a result. The provider acted promptly to address these concerns during the assessment and provided assurances that improvements had been made.

People now benefited from detailed person-centred care plans and risk assessments that accurately reflected their needs and provided staff with clear guidance on how to support them safely.

Staff demonstrated a good understanding of people's individual preferences, risks and support needs. They also showed good knowledge of safeguarding procedures, the Mental Capacity Act (MCA), and how to escalate concerns appropriately to protect people's rights and wellbeing.

Professionals spoke positively about the service and highlighted effective communication, good incident management processes and positive staff engagement with people receiving care.

Some staff raised concerns about their wellbeing but felt supported and felt able to raise concerns with leaders.