Archived: Rock House

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant services were not planned or delivered in ways that met people’s needs.

The service was in breach of legal regulation in relation to person centred care.

This service scored 29 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not make sure people were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs. At the last inspection, people did not consistently receive person centred care. At this inspection, the provider had not made sufficient improvements. People were not always supported or encouraged by staff to do things that they enjoyed. For example, we reviewed 2 weeks of daily records for 1 person. 12 of the 14 days staff detailed the person was consistently ‘pacing the corridors or hallways’. The records failed to detail how staff had supported this person to engage in activities they were interested in.

During the inspection, one person told us they were ’bored’. The persons daily notes detailed very little engagement or support to access activities they were interested in. one staff member told us, ‘I think clients could do more activities, they tend to get bored very easily, and that leads into spiralling.’

The provider had not ensured that meal-times and meal planning was person centred. There was a blanket approach that meant it was each residents responsibility to manage their nutrition, including meal planning, food shopping and cooking. Whilst this may have supported some people with their independence, it was not the case for all people in the home. Some people were not supported to eat healthy and nutritious meals. Daily notes for one person detailed that out of 14 consecutive days, on 7 of those they had a takeaway with 5 of those being consecutive days. Poor nutrition can have a detrimental impact on people’s health and wellbeing, particularly people with significant health conditions including diabetes.

There were significant shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not joined-up, flexible or supportive of choice and continuity. For example, some people often declined their medicines and it was not clear what action had been taken to support this person to take their medicines more regularly. One staff member told us that they wanted to engage with the GP to see if their medicine times can be altered to a time that suits the person, however this had not yet been actioned.

People often declined healthcare and medical appointments. Staff would document if they had declined to attend and they would support the person to rebook another appointment. In most cases, staff supported people to attend their appointments when they accepted. However, there were no effective systems in place to ensure ongoing appropriate support for people with their mental health and physical health to ensure people remained well.

The provider did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs. People’s care plan did not always contain information that was up to date. For example, one person’s care plan detailed that their next of kin was an employee of service. However, this employee had left the service in 2025 and had no ongoing involvement with the service. This meant that the person did not have valid next of kin details.

People were supported to have their information in an accessible format if they wished. For example, people who had difficulty reading were supported by staff to read letters addressed to them, with their consent.

The provider did not make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not involve people in decisions about their care or tell them what had changed as a result. The provider had not ensured that complaints and concerns raised by people were formally recorded and responded to. We asked the manager if there was a complaints log and they told us that complaints were not formally recorded but were addressed with that person. There was no system in place to ensure complaint and concerns had been actioned appropriately.

The manager had implemented a system to gather people’s views, including and ‘afternoon tea’ monthly which detailed the concerns that people had in relation to the running of the service. Whilst these meetings were recorded, the actions following these meetings were not documented and we could not be assured they had been considered or addressed.

The provider did not make sure that people could access the care, support and treatment they needed when they needed it. The provider did not use people’s feedback to actively seek to improve access for people more likely to experience barriers or delays in accessing their care. For example, people shared with the manager during, a residents meeting, that they felt staff did not understand what people wanted and needed due to language barriers. Following this meeting it was not recorded what action was taken to address this barrier and how they would support people to ensure their needs are understood.

Relatives told us they felt people were not supported to access the community or encouraged by staff to take part in activities that could support their health and wellbeing. One relative told us ‘Poor [person] at the moment, from my observation [person] spends most of [person] time in their room, it’s not healthy for [person].

People were supported to attend medical appointments, and this was documented when they attended.

Staff and leaders did not listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not tailored in response to this. People were not always supported or empowered to make choices that would support their positive outcomes in relation to their health and wellbeing. For example, the support from staff was inconsistent when encouraging people to make healthier lifestyle choices.

People’s positive experiences and outcomes were limited as they did not receive their 1-1 support hours to encourage and empower consistent healthy lifestyle choices. Relatives told us they felt their loved one did not always get this support they needed, they were not aware of 1-1 hours and were not assured the relative was getting the level of support they were entitled to.

People were not always supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life. People did not always have end of life care planning considered in their care and support plans. At the time of the inspection, there was no one who was being supported with end of life care. However, people were being supported who had significant mental health conditions including people who placed themselves at risk through intentionally harming themselves. This meant there was an increased importance of discussing people’s wishes around end of life in a compassionate and open manner.

People’s care and support plan had detailed goals for the future, however it was not clear how staff would support people to reach these goals that had been set. There was a lack of oversight to ensure goals were attainable and clear steps on how staff will support the person to achieve them.