Roche Abbey Care Home

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

We found 1 breach of regulation The service did not have a positive culture that was person-centred, open, inclusive and empowering. The service did not have an effective quality assurance system. The provider did not have sufficient oversight to monitor the quality and safety of the service and to ensure there was effective leadership in place. We received mixed views about the quality of the care provided from relatives. We found people were not always supported to have maximum choice and control of their lives because choice was not always actively promoted. The quality of people’s care records and risk management required improvement. The provider had not ensured that safety events were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The management team informed us there were a lot of issues to address and were aware of the concerns. They told us they needed time to address them and the number of professionals coming in were hindering that process. The management team had undergone a change and the service is currently being managed by the regional manager and clinical lead.

The service did not have a positive culture that was person-centred, open, inclusive and empowering. The home had recently changed management team and the regional manager was carrying out the role of acting home manager with the support of a clinical lead/deputy and a clinical lead. There was no evidence of the staff team including the management team working together to achieve good outcomes for people. The management team was in its infancy. There was a lack of prioritisation around protecting people’s human rights and ensuring they received safe, high quality, compassionate care. The provider did not have sufficient oversight to monitor the quality and safety of the service. Quality monitoring visits undertaken by the nominated individual had not identify concerns we identified during our assessment. The provider had failed to learn lessons and take action to improve the service since our last inspection.

The management team informed us there were a lot of issues to address and were aware of the concerns. The management team had undergone a change and the service is currently being managed by the regional manager and clinical lead. The current management team acknowledged they needed to improve outcomes for people. Staff told us there had been several managers who had stayed a while them moved on. Staff had found this unsettling and left them without clear guidance and direction.

The provider was aware of the issue of poor culture within the service. The provider told us they had completed staff meetings to address issues. Poor culture may affect the quality of people's care and have detrimental impact on staff. Our findings during the assessment showed further action was required to ensure people always experienced person-centred care.

The management team informed us there were a lot of issues to address and were aware of the concerns. The management team had undergone a change and the service is currently being managed by the regional manager and clinical lead. The current management team acknowledged they needed to improve outcomes for people. Staff told us there had been several managers who had stayed a while them moved on. Staff had found this unsettling and left them without clear guidance and direction.

Some people and relatives told they had not been invited to attend any resident and relatives’ meetings or asked to fill in survey. This showed the systems in place to actively seek people's views required improvement. The last relative and residents meeting documented was January 2024, no further meeting had taken place. The new management team informed us they had recently sent out a quality questionnaire and were awaiting feedback. Evidence of the previous quality questionnaire was not available and the current management team were not aware when this was last completed. Relatives were aware of the service's complaints process. People felt they could express their views to staff if they had any concerns. We found people were not always supported to have maximum choice and control of their lives because choice was not always actively promoted. People who had raised concerns, ideas and suggestions had not always been listened to.

The current management team told us that the home had previous had no oversight. This had left staff feeling unsure what to do and feeling lost. The current management team felt the staff team needed guidance and direction to provide safe and effective care and support.

There was no evidence to show equality and diversity was promoted, and the causes of any workforce inequality identified.

The management team told us there had been no audits completed in April 2024 due to change of manager, however, audits for May 2024 had commenced. Care plans had been transferred on to a different electronic system in April 2024 and the management team told us they had put everything in place with a view to personalising care plans and complete and update risk assessments where required. The management team acknowledged this required further work.

The service did not have an effective quality assurance system. The quality of some audits undertaken was poor. As a result, the quality of the service had not been improved since the last inspection. The provider did not have sufficient oversight to monitor the quality and safety of the service and to ensure there was effective leadership in place. The management team were planning to complete an action plan to address the concerns raised by professionals. Audits which had been completed had not identified the concerns we found regarding person-centred care, infection prevention and control, medicine management and poor oversight.

We received mixed views from relatives about the quality of care provided to their family member. One relative said, “They [staff] sent me in [to hospital]” Told me they recognised she was unwell and arranged ambulance. People and relatives also told us the doctor visits regularly. One person said, “Showers and things are lacking." One relative told us they had heard a member of staff asking if anyone wanted a shower. When no-one responded the member of staff said, “Good, because I haven’t got time."

The management team informed us there were a lot of issues to address and were aware of the concerns. The management team had undergone a change and the service is currently being managed by the regional manager and clinical lead. The current management team acknowledged they needed to improve outcomes for people. Staff told us there had been several managers who had stayed a while them moved on. Staff had found this unsettling and left them without clear guidance and direction.

The local authority shared concerns about the quality of care and safety of people using the service. Professionals working alongside the service had identified concerns and were taking action to ensure the management team were addressing them. Concerns included weight loss, medicine management, staffing levels, nutrition and hydration, personal care, poor care documentation and decline in people's health which had not always been escalated or managed appropriately to keep people safe.

People's assessments needed to be more detailed to ensure all their needs were identified. The quality of people's care records and risk management required improvement to enable effective information sharing between the service and healthcare professionals.

The management team informed us there were a lot of issues to address and were aware of the concerns. The management team had undergone a change and the service is currently being managed by the regional manager and clinical lead. The current management team acknowledged they needed to improve outcomes for people. Staff told us there had been several managers who had stayed a while them moved on. Staff had found this unsettling and left them without clear guidance and direction.

Since the last inspection the provider had not improved. The home had deteriorated since our last inspection and no lessons have been learned or systems devised to ensure improvement. We found people were not always supported to have maximum choice and control of their lives because choice was not always actively promoted. The quality of people’s care records and risk management required improvement. The provider had not ensured that safety events were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.