Working at Rosedene Nursing Home

Medication safety has gaps like missing instructions for hidden meds, crushing pills when not allowed, and no dates on strong drugs which risks errors on shift.

we found instances where medicines records did not state how covert medicines should be administered. We also found instances where medicines were crushed to administer them, when pharmaceutical instructions stated that the medicines should not to be crushed. We found instances where controlled medicines were not labelled by staff to state the date they were opened.

Managers overlook issues because audits miss problems in medication checks and safety tests.

audits did not always identify shortfalls. For example, medicines audits did not identify shortfalls around covert medicines management, and safety audits failed to identify that fire alarm and emergency lighting systems had not been tested for months.

No full-time activities coordinator means shifts often lack engagement variety and feel like routine care.

the service did not have an activity coordinator in post. A member of staff was covering the position and was enthusiastic about the role. Whilst we observed periods of time in which people were neither active, nor engaged.