Archived: Rock House

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question inadequate. At this assessment the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, management of risks relating to people’s health, safe and effective staffing and fit and proper persons employed.

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.

At our last inspection systems were not robust to ensure lessons could be learnt from incidents and accidents. At this inspection, the provider had failed to make sufficient improvements. The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not investigate or report safety events. Staff supervisions records detailed that incidents were not always being recorded or reported by staff. Incidents that had been reported by staff, lacked detail to ensure appropriate action could be taken to ensure people’s safety. For example, one incident reported by staff failed to disclose the potential alleged abuse by another staff member towards a person. This was not disclosed straight away and therefore immediate action was not taken to address the incident. Oversight of incidents was not robust and actions following incidents were not consistently detailed. Trends and patterns analysis had not been completed to ensure lessons could be learnt. For example, where people refused their medication, there was no evidence of an analysis of these incidents to identify what action could be taken to support the person to take their medicines more regularly.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. People received continuity in relation to the staff team that supported them. However, the competency and skills of these staff did not ensure that people’s risks relating to their care journey were well managed. For example, staff we spoke with did not have a good understanding of who was at risk of choking.

The provider made referrals to healthcare professionals such as the speech and language therapy team (SALT) team and mental health services. However, this did not always result in staff providing appropriate or safe support to people as there was an absence of competency and skill in the leadership and staff team. This had a detrimental impact on people’s safety, and on their mental health.

At the last inspection, the provider had not ensured people were protected from the risk of harm and/or abuse. At this inspection, the provider had failed to make sufficient improvements and people were still at risk of harm and/or abuse. The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. The provider had not ensured that all potential safeguarding incidents had been reported to the local funding authority. For example, an incident that involved the alleged abuse of a staff member had not been reported by the service to the local safeguarding team. Following the incident, the provider had failed to ensure they completed their own actions detailed within the disciplinary process to ensure the continued safety of people. For example, it was identified that a staff member needed refresher training and increased supervisions to ensure they were competent to support people safely. However, there were no records that increased supervision and refresher training were completed. People were at continued risk of harm.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. At the last inspection, the provider had failed to ensure risks to people’s health were well managed, including risks around self-harm. At this inspection, the provider had addressed the risks relating to self harm but had not addressed all the concerns relating to people’s health risks, including constipation risks and choking risks.

The provider had not ensured there was effective risk management for people at risk of constipation. One person was at risk of constipation and was prescribed an ‘as required medicine’ to support them. There was no guidance in place to ensure staff supported the person to have their ‘as required’ medicine when needed. Staff told us they might ask the person if they needed this medicine but this was not recorded. There was no oversight to ensure action could be taken in a timely way if the person became constipated.

Risks relating to people’s mental health needs were not consistently well understood or well managed. Staff had not fully understood or identified risks relating to a decline in people’s mental health. One person’s daily notes for a 2 week period, detailed that almost every day they would ‘pace the hallways’ or ‘pace the house’. The person’s mental health support plan referred to pacing as an early relapse sign. There was no evidence that this had been identified or explored by staff and leaders to understand if this person needed any further support with their mental health. The person’s care plan did not detail if this was normal behaviour for that person. Furthermore, if this was normal behaviour for that person there was no guidance on how staff should identify the difference and explore if the person may be experiencing a relapse.

Choking risks were not always well managed. One person was at risk of choking and the guidance in place for staff was not updated after a choking incident. Whilst staff responded appropriately during the choking incident, the guidance for staff was not updated following this. Staff we spoke with did not have a clear understanding of choking risks. Most of the staff we spoke to told us there was no one that was at risk of choking. We shared this feedback with the manager to ensure they could address this urgently.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

At the last inspection the provider had not ensured that risks relating to the environment were well managed and mitigated. At this inspection, the provider had not made sufficient improvements. At the last inspection, we identified that radiators were unguarded and posed a significant burns risk. At this inspection, radiators were still unguarded. Staff were told to take the temperature of the radiators in the home in the morning and the evening. On one of the days the radiator was consistently above the recommended temperature in the morning and the evening. The manager said it is reported to the maintenance team but it is not clear what action was taken to address the hot radiators and mitigate the risk of burns. The provider had investigated covering the radiators, however, this had not yet been completed, and we saw incidents where people had fallen or tripped near exposed radiators.

The provider had also not ensured that flooring was free of trip hazards. For example, the sloped flooring down towards the kitchen was uneven and posed a trip hazard. There were a number of areas within the home that needed repairing/ for example, a person’s bedroom and the office woodchip was peeling off, and the stairs to the basement where the banister had been re-attached to the wall but there were holes where it was previously attached to the wall.

Risks relating to fire safety had not been addressed. Fire safety deficiencies were identified in October 2025, which included the practice of a fire evacuation at night had not been completed. Night time fire evacuation practise is essential to ensure staff can support people to evacuate safely with the lower staffing levels. At the time of this inspection, this had not been completed.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The provider had not ensured there were enough skilled staff to support people safely with their assessed needs, in particular needs relating to people’s complex mental health conditions. Some people had additional 1-1 support hours to ensure they received personalised and specific 1-1 support from a dedicated member of staff. This was not happening for anyone who had additional 1-1 hours. This had a major impact on people’s mental health and well being. People’s daily notes detailed that their commissioned 1-1 hours were not being delivered. In addition to this, staff told us that 1-1 hours were recorded for activities that were not specifically for dedicated 1-1 time, such as administering people’s medicines, admin and wake night checks. Daily planners were used to give direction for staff, however people’s full 1-1 hours were not scheduled. For example, one person was assessed as needing 4 hours of 1-1 support per day, however only 2 hours were being scheduled in daily and there were not enough staff scheduled to ensure the 4 hours could be allocated. The 2 hours had been scheduled as a 1-1 chat with staff or cleaning. There was no evidence of meaningful activities for that person being scheduled.

As well as not having sufficient staff on duty to meet people’s assessed needs in terms of their mental health and physical health, there were insufficient staff to ensure people received adequate support to plan, shop, prepare and eat meals. The staff on duty were responsible for supporting everyone with their care and support needs, including preparation of meals, laundry and cleaning. Current staffing levels were unable to adequately support people with their needs, meaning that people did not receive appropriate support in any area of their lives.

Safe recruitment processes were not always followed in line with Schedule 3 of the Health and Social Care act 2008. Schedule 3 outlines mandatory pre-employment checks for staff in health and social care. It requires proof of identity, criminal record checks (DBS), full employment history, references, qualifications, and health fitness checks. These ensure workers are fit to provide care.We found gaps in staff recruitment files. For example, we found some staff did not have complete work history ensuring gaps in employment had been explored and some references had not been verified to ensure they came from the right person.

Staff had not received consistent support to deliver safe care. Supervision records showed that all staff received a supervision in November, however prior to this date, most staff had not received a supervision in 2025.

Staff had not received training that was relevant to their role. For example, not all staff had completed dementia training and the service supported at least on person with a diagnosis of dementia. Some relatives told us they did not feel confident with the staff supporting their loved one, one relative told us ‘At the moment I don’t have confidence in this team, we need to train them up to be more resourceful and educational.’

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The service was not clean, and visibly dirty in places. For example, walls had stains where liquids had been split and not cleaned. The carpets were visibly dirty and in need of hoovering. Staff had disposed of PPE in the kitchen bin, which had a broken lid meaning it could not be utilised without touching the bin.

People were supported by staff to help maintain the cleanliness of their rooms, however people often declined this support. Whilst basic cleaning checks were in place, these were not effective or robust as we did not observe the service to be clean.

The provider did not always make sure that medicines were safe and met people’s needs, capacities and preferences. The provider had not always ensured that medicines were stored safely and in line with NICE (National Institute for health and Care Excellence) guidelines. Temperature checks for the medicines room were not consistently being completed to ensure the safety and effectiveness of the medicine. NICE guidelines detail that room temperature medicines should be stored between 15 and 25 degrees and checked daily. One temperature check recorded a reading of over 25 degrees with no action taken by staff to reduce the temperature.

The provider did not have robust monitoring systems in place to be proactive when people regularly refused their medicines. Whilst staff recorded when people refused their medicines on the incident log, there was no clear plan or proactive approach to support and encourage people to take their medicines. A staff member told us that they were going to speak to people’s GP and discuss what changes can be made to encourage people to take their medicines more regularly. However, this had not happened prior to the inspection.

The provider had not ensured sufficient monitoring was in place regarding people who were prescribed anti-psychotic medicines. People who are prescribed anti-psychotic medicines require regular health reviews with their GP to review any symptoms or side effects. The provider could not evidence people were supported to attend these reviews and staff confirmed this.

The provider had recently implemented an electronic medication system which staff were in the process of learning how to navigate. Staff told us they had completed training on medicines administration and management.