Roche Abbey Care 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

We identified 2 breaches of regulation. Risks associated with people’s care had not always been managed to keep people safe. People requiring pressure relief, did not always receive this constantly and information to guide staff was not always in place. Some care records lacked detail in relation to nutritional intake and hydration. People did not always receive their medicines as prescribed. We observed poor infection, prevention and control practices which meant people were not always protected from cross infection. People were at risk of harm from unmanaged hazards in the premises. This included items being stored in stairwells, bedroom furniture not being securely fastened to the wall, and furniture being used to prop open a bedroom door. The systems in place to learn from accidents and incidents required improvement. There were sufficient staff at the service, although they lacked leadership and were not deployed effectively to meet people’s needs. There were shortfalls in the safe recruitment of staff.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We asked people if they felt safe living at the home and received conflicting views. One person said, “Yes, I feel safe.” A relative said, “From what I have seen of the place, I really like it.” Whilst another person and their relative said, “I don’t know, I couldn’t say [if relative is safe or not]. I suppose safer than they would be at home.”

The management team informed us that accidents and incidents had not been analysed since March 2024 and the team had started to look at how this process could be improved. Staff told us there had been several changes in the management team and felt they got used to one manager and how they operated and then another manager would take over with different procedures and ideas. Staff told us they found this unsettling.

The provider did not have effective systems in place to learn from incidents. Accidents and incidents were recorded, and on occasions, trends and patterns identified. Actions were not taken to mitigate future incidents. For example, there had been no accident and incident analysis completed for April 2024. The provider could not evidence timely action had been taken to mitigate risks and ensure lessons were learned.

We received some mixed views about the quality of care provided and the involvement of other healthcare agencies. Some people shared details of all the different healthcare professionals involved in their care. Some relatives felt staff needed to follow up referrals to healthcare professional more often. One person informed us they did not choose to live at the home. Although staff and leaders were aware of this, minimal action had been taken to support the person. One person said staff had recognised they were not well and arranged an ambulance. They said, “They [staff] sent me to hospital when I was unwell.”

The management team acknowledged some areas required development. We spoke with the management team regarding a person who did not wish to reside at the home, but they had not sought appropriate support to assist the person to make an informed decision.

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.

Processes were in place to enable a smooth transition between services and to reduce the impact on people. However, the quality of some people's care records and/or medication records had insufficient detail to enable effective information sharing.

We asked people if they felt safe living at the home and received conflicting views. One person said, “Yes, I feel safe.” A relative said, “From what I have seen of the place, I really like it.” Whilst another person and their relative said, “I don’t know, I couldn’t say [if relative is safe or not]. I suppose safer than they would be at home.”

The management team was aware of safeguarding concerns highlighted by visiting professionals. These had not been documented or recorded for the purposes of learning lessons.

We observed staff interacting with people and found they were task focused. However, most interactions were kind and caring, although some people had to wait to receive support.

The provider had a safeguarding log in place; however, this had not been kept up to date and therefore did not reflect current concerns or actions taken to address them. People’s care plans did not record any details where deprivation of liberty safeguard in place (DoLS) had been authorised. We identified a lack of information regarding deprivation of liberty safeguards and conditions attached to them. For example, where people had DoLS in place there was no mention of this within their care plans. Where conditions were in place, there was no record regarding how these were being monitored. One member of the management team had been in post 8 weeks and had identified 8 people who required a DoLS application. These had not previously been identified. Accurate, complete and contemporaneous record in respect of people were not in place and your monitoring systems failed to identify this.

People were not always involved in decisions about their care and risks associated with people's care had not always been identified or managed well. We asked people if they felt safe living at the home and received conflicting views. One person said, “Yes, I feel safe.” A relative said, “From what I have seen of the place, I really like it.” Whilst another person and their relative said, “I don’t know, I couldn’t say [if relative is safe or not]. I suppose safer than they would be at home.”

Staff and leaders were not always knowledgeable about risks associated with people’s care. Some staff were unable to explain how risks associated with people's care were managed to keep people safe.

We observed that staff took meals to people and left the meal on the table with no support offered. Staff provided people with drinks but on several occasions left drinks out of reach. Through our observations, discussions with people, their relatives and staff and review of care records we found that people were not involved in decisions about their care and how care was provided to them. We saw that staff did not always explain the tasks they carried out including when providing care to people. Foe example, 1 person called for assistance using the nurse call system and waited 20 minutes before staff answered the call. Staff informed the person they would have to wait until desserts were served. The person replied requesting to use the toilet as they were desperate and visibly distressed. The staff member carried on serving desserts.

Risks associated with people's care were not always identified and actions had not always been taken to mitigate risks. Some people required risk assessments, but these were not always in place to ensure people's needs were met in a safe way. People who required assistance to eat their meals were left unsupported. One of these people was at risk of loosing weight and required a fortified diet but were only offered a sandwich. Personal Emergency Evacuation Plan (PEEPS) were generally poor and lacking information. For example, one person's bedroom door had a keypad lock which required a code to enter the room. The code was not included in the persons. PEEPS, minimising access in an emergency

The environment was not always managed safely. Bedroom doors were fire doors but did not have quick release equipment installed so that doors could be kept open safely. One person told us they prop open the bedroom doors with chairs or tables sometimes. Also, people were isolated in their rooms and unable to see into the communal corridor. The upstairs sitting room was very warm and drinks were not readily available for people. .

Staff told us equipment was available for moving and handling and they received training to carry out their role safely. The management team were aware of environmental issues that needed to be addressed.

We carried out a tour of the home and found some environmental factors which posed a risk to people. For example, one person’s bedroom furniture was not attached to the wall and therefore a risk of falling on someone. Items such as electronic scales were stored in the stair well creating an obstruction. The management team removed these immediately. Several bathroom fans were not in working order. The provider assured us these issues would be resolved.

Processes in place to monitor and maintain the environment were not always effective. We found issues which posed a risk to people using the service which had not been identified or addressed to ensure people lived in a safe environment. The service did not adequately protect people from the risk of fire. We found people had personal evacuation plans (PEEPs) in place, however, these did not contain key information such as where people’s bedrooms were located and pictures of people, so that people could be easily identifiable in case of a fire. We asked the provider for a copy of the service’s fire risk assessment; however this was not provided at the time this was requested. The provider sent us a copy of a completed fire risk assessment at a later date, which identified some hazards, however actions were not always taken to reduce the risks from these identified hazards.

People gave mixed views regarding the number of staff available. One person said, “Enough? No, they should have more carers.” One relative said, “I don’t think there are enough staff. I have had to wash [relatives] hair as it was greasy.” One person said, “There are enough staff and They have the right skills.”

We received mixed views from staff regarding staff compliment within the home. Ancillary staff felt they were sometimes short staffed. When staffing was reduced, they were unable to carry out deep cleans of the home and focused on bathrooms, toilet and communal areas. Other staff felt there were sufficient staff but acknowledged they needed leadership and guidance.

There were sufficient staff available during our site visits. However, some people were left alone when they required support and some people had to wait significant amount of time to be assisted. We observed a lack of leadership and direction.

Staff were not always recruited safely. One person started October 2023 and there was no evidence of pre-employment checks carried out by the provider. Following our inspection the provider carried out a full audit of staff files and identified further gaps in the recruitment process. We observed there were enough staff to support people. There was a lack of staff supervision and staff didn't feel supported.

People were not always protected from the risk and spread of infection. People and their relatives told us their rooms were not always clean and said personal hygiene standards were lacking. For example, one relative said, "I don’t think there are enough staff. I have had to wash [relatives] hair as it was greasy.” We observed poor infection control procedures being carried out by staff.

Ancillary staff felt they were sometimes short staffed. When staffing was reduced, they were unable to carry out deep cleans of the home and focused on bathrooms, toilet and communal areas. The management team told us they were aware of concerns regarding the cleanliness of the home and were working towards improving these standards.

People were not always protected from the risk of infection. We observed staff did not follow guidance regarding infection prevention and control. Staff walked from bedrooms with soiled items which were not contained in a bag, and proceeded to the bathroom where items were disposed in a clinical waste bin. Staff then changed their gloves but did not wash their hands before carrying out personal care with another person. This created a malodour and put people at risk of cross infection. There was a lack of useable hand washing facilities throughout the home with lack of hand sanitiser and soap dispensers empty. We carried out a tour of the service and found areas within the home were visibly dirty. These concerns increased the risk of cross contamination.

The systems used by the provider to monitor infection, prevention and control practice were not effective in practice and did not ensure people were always protected from the risk of infection. There had been a lack of oversight from the management team and audits in place to monitor infection prevention and control had not identified the concerns we found during our assessment.

People and relatives did not share any concerns about the management of medicines. However, our findings during our site visit showed we could not be confident that people were being supported appropriately with medicines.

Staff involved in the handling of medicines had received training about medicines. Staff were assessed as competent to support people with their medicines. However, the systems in place to check staff handled medicines safely required improvement.

Documentation did not always support that medicines were managed safely. For example, records were poor and did not always evidence people had recieved their medicines as prescribed, and body map documentation was not always completed. Some people were prescribed medicines on an 'as and when' required basis, but protocols in place to ensure safe administration, lacked detail and we found one person did not have a protocol in place. These concerns had not been identified as part of the providers auditing systems.