Rockfield 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 good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment, and staffing.

This service scored 47 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider had effective systems and processes to identify, report and review accidents and incidents. Managers and senior managers reviewed incident reports, identified lessons learned, and carried out debriefs with staff and those involved. We saw evidence of action taken to address shortfalls following incidents. For example, after one incident, managers recognised that environmental adaptations could reduce the risk of recurrence and made necessary changes. Lessons learned from accidents and incidents were clearly communicated to staff.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The pre-admission and admission processes were not always effective in identifying and documenting risks or ensuring appropriate measures were in place before people moved into the service. However, transition periods were arranged to provide support to people prior to moving in, and there was evidence that positive steps had been taken to help some people settle into the service.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

People told us they felt safe living at Rockfield House. One person said, “The service has helped keep me safe.” Family members we spoke with also supported this view.

The provider made appropriate safeguarding referrals, which were investigated as required. However, we found some instances where safeguarding concerns had not been notified to CQC in line with requirements. The duty manager submitted these notifications retrospectively following our feedback.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

For example, a provider review of one incident showed staff had not followed care plans, and behaviours had not been identified to allow the use of de-escalation techniques. The provider responded appropriately, reinforcing the importance of staff reading and following care plans to support people safely.

We also identified some risk assessments and care plans were not always updated or in place to reflect people’s current needs.

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

The provider did not have an environment risk assessment in place; therefore, we could not be assured all potential hazards around the home had been formally identified or managed, increasing the risk of harm to people.

Some areas of the home required upgrades and redecoration; however, refurbishment work had already begun and was ongoing at the time of the inspection.

During the assessment, we observed some fire exits blocked by furniture and fire doors with gaps around them. The provider took immediate action, removing obstructions and replacing doors without delay.

A maintenance person carried out regular weekly and monthly checks around the home, including fire safety checks. Staff maintained a log to ensure repairs were reported and completed promptly.

The provider did not always ensure staff were recruited safely or they received effective support, supervision and development.

Safe recruitment checks had not always been completed. For example, gaps in employment for some staff had not been explored. In addition, not all staff had received regular supervision or annual appraisals in line with the provider’s policy. We discussed these shortfalls with the provider, who took immediate action. The provider’s workforce team carried out a full audit of all staff files, generated an action plan, and scheduled supervisions to be completed for all staff by the end of September 2025.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff had received training in infection, prevention and control, and the provider carried out some audits. The home was generally clean, however we did identify some gaps in cleaning records so could not be assured that areas of the home were being cleaned as regularly as was required.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

For example, people prescribed high risk medication, did not have appropriate risks assessments in place. Therefore, they were at risk of experiencing side effects and a deterioration in health as staff had no guidance on how to identify and respond to these risks. Similarly, for some people prescribed ‘when required’ medication, guidance was either missing or lacked sufficient detail. This placed people at risk of not receiving their medication when required.

Risk assessments were also not in place for people prescribed emollient creams, which posed a potential fire risk. The manager implemented these immediately following our feedback.

We also found missing administration records for some medicines and gaps in the medication booking in process. We fed this back to the provider who completed a full internal medication audit, and generated an action plan to address the issues identified.