Updated 20 November 2025
Date of assessment: 8 to 22 January 2026. Rose Villa Nursing Home is registered to support up to 36 people. This includes older people, people living with dementia and/or a physical disability. At the time of our inspection there were 27 people using the service. The assessment included 2 on site visits, with other information and evidence reviewed remotely. The assessment was completed to follow up on the action we told the provider to take at the previous assessment.
The last assessment for this service was completed on 16 May 2023 and there were breaches of regulation identified around safe care and treatment, dignity, person centred care, staffing and governance of the service. During this assessment we found breaches of the legal regulations in relation to safe and effective care, person centred care, fit and proper persons and governance. The provider had been in breach of legal regulations relating to safe care and treatment, good governance and person centred care for the last 3 assessments.
The provider had made some improvements since the last assessment, including introducing a governance structure and implementing systems and processes to monitor the quality of the service. However, these new systems were not consistently applied and were not effectively embedded or maintained over time. As a result, regulatory breaches continued.
Governance processes had failed to identify the shortfalls we found during this assessment. Safe recruitment checks were not always completed, and care did not always meet people’s needs or reflect their preferences. New systems did not ensure a safe environment, nor did they adequately protect people from harm or abuse. Risks associated with people’s care were not always identified or managed effectively to reduce potential risks or risks to others.
People did not always receive person‑centred care. Records did not consistently reflect their wishes or preferences; and staff did not always communicate effectively to understand what people wanted or needed to support their emotional well‑being.
Infection control was not always maintained, and staff did not demonstrate a good understanding of safe practice in the use of personal protective equipment.
The provider did not always ensure appropriate checks were completed for staff working in the service, so we could not be assured they were suitable and safe to work with vulnerable people.
Improvements had been made in the management of medicines, and people received their prescribed medicines safely.
People were supported to exercise choice and control over their lives. Staff acted in the least restrictive way possible and in individuals’ best interests, and the service’s policies and systems supported this approach.
The provider was working with an external care consultant, and a new manager had been appointed to help drive improvements within the service.
In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward. We have asked the provider for an action plan in response to the concerns found at this assessment.
This service has been in Special Measures since May 2025. The provider demonstrated improvements that have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.