Archived: Rock House

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question inadequate. At this assessment the rating has remained inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to good governance.

This service scored 32 (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 have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. At the last inspection, the provider had not addressed the closed culture at the service. At this inspection, the provider had not made sufficient improvements to address the closed culture. A closed culture is a poor culture that can lead to harm and people’s human rights breaches such as abuse. Staff at all levels had not prioritised safe, high-quality, compassionate care. Staff were not always respectful when supporting people during periods of distress. Staff did not always use language that was appropriate and dignified when recording incidents and daily notes. The manager told us they had concerns with the staff team relating to a poor culture and there was still a lot of work to do to address this. Staff survey results from October 2025 indicate a low morale amongst staff, comments from staff include ‘Little autonomy’ and in response to the question around management, ‘There are no worst things’. Since the last inspection, the provider had failed to implement an effective action plan in relation to a closed culture at the service to ensure any progress was documented and evidenced.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. The provider had not ensured that examples of poor culture that may affect the quality of people’s care were fully addressed and mitigated. For example, actions outlined in a staff member disciplinary meeting were not followed through, this included re-training in de-escalation techniques. The provider could not be assured that the staff member was capable of supporting people in a way that was compassionate and safe.

There was not a positive culture of speaking up at the service. Staff were not always open when recording incidents. For example, an incident was not formally recorded when a staff member had an altercation with a person and then verbally and physically abused them. This was later reported to senior management by someone else.

Whilst the service had sent a staff survey out to be completed, there had only been 3 responses. The provider had not evidenced how they addressed the low level of responses from staff any why staff did not complete the survey. There was no actions on how they would gather staff feedback following the low number of responses they received via the staff survey.

The provider did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. Whilst the provider had given staff the opportunity to complete a staff survey, the number of responses was low. The provider had also failed to address the concerns raised in the staff survey. For example, one response detailed more activities were needed and team bonding. Staff told us that morale was low amongst the staff team but it was slowly starting to improve.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. At the last inspection the provider had failed to ensure effective systems were in place in relation to the governance of the service. At this inspection, the provider had started to implement new systems, however these were not embedded and failed to identify the concerns we found during this inspection. Actions identified in audits had not been addressed. For example, fire safety risks in relation to safe night time staff numbers for evacuation had not been addressed. The audits failed to address the poor level of detail being recorded in people’s daily notes, this included the lack of 1-1 hours being carried out by staff.

Leaders had not implemented relevant or mandatory quality frameworks, recognised standards, best practices or equivalents to improve equity in experience and outcomes for people using services and tackle known inequalities. Best practice guidance in relation to Dementia care had not been considered.

The provider had not ensured they considered and implemented relevant or mandatory quality frameworks in relation to people with a learning disability and/or Autistic people. The RSRCRC guidance outlines that we expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. People did not consistently receive person centred care, the provider had failed to prevent a closed culture at the service and staff were not consistently empowering people in their daily lives.

The provider had not addressed the blanket approach for supporting people with their nutrition, this meant some people at the service were disadvantaged and did not have access to healthy meals to promote their health and wellbeing.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. The provider had not always ensured that potential safeguarding incidents were reported to the local safeguarding teams.

The provider had made referrals to other health care professionals such as the mental health services and staff supported people to attend those appointments when they accepted them.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. At the last inspection, the service was rated inadequate, at this inspection, the provider had not made sufficient improvements and remains inadequate. Staff and leaders did not have a good understanding of how to make improvement happen. The approach was not consistent and did not include measuring outcomes and impact. Whilst the manager had implemented processes for staff and people to feedback, there was evidence of learning from people’s feedback.

The provider had not ensured that lessons were always learnt following incidents and people’s care plans updated to reflect changes in care. For example, following a choking incident, the persons care plan had not been updated to reflect this and staff we spoke were not confident to describe who was at risk of choking.