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

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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

This service scored 54 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Residential managers from all the provider’s homes met monthly to share ideas, raise concerns and discuss new initiatives. The manager also held monthly staff team meetings, which included discussions around a different value each month. Staff were encouraged to nominate colleagues who demonstrated the chosen value, with nominees receiving a prize.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

At the time of the assessment, the manager was in the process of applying to be the registered manager with CQC; this has since been confirmed. Leaders were open about issues identified within the service and were working towards an action plan. They were responsive to feedback received following our assessment and showed passion for making changes to ensure people received care that met their needs. They were committed to continuing to drive improvements. There was regular senior management presence in the home.

Feedback from staff was mixed. Some staff acknowledged the positive changes made since the new manager was in post, while others felt there were still improvements needed in relation to management style and action taken by leaders.

People did not always feel they could speak up and that their voice would be heard.

Staff were given opportunities to speak up, but most told us they did not always feel listened to or able to raise concerns. They provided some examples where they had raised concerns with the manager and these had not been actioned. Comments included, “Some staff aren’t listened to,” and “Most staff won’t speak up.”

Other staff members told us they were able to speak up and did feel listened to. One staff member said, “Management are approachable, I feel listened to”.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

For example, staff recognition schemes were in place. The manager shared examples of how support and adjustments were made to accommodate staff members personal situations and promote their wellbeing.

However, some staff we spoke with raised concerns regarding the equity of workload, feeling some staff were given preferential treatment in terms of the work they were allocated.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

There was a lack of provider oversight and effective auditing. Although audits were in place, they did not always identify the concerns we found during out assessment or ensure actions were completed to resolve issues and improve the service.

For example, external and internal medication audits completed between April and July 2025 identified concerns with guidance for ‘when required’ medicines; however, this remained an issue at the time of our visit. The provider failed to ensure these actions were completed.

Medication audits also did not identify some of the concerns we found, such as missing risk assessments for high risk medicines and prescribed emollient creams.

A provider visit completed on 6 August 2025 identified concerns with care plans. These had not been addressed, as we found the same issues during our visit. The audit also showed several actions from the previous visit in April 2025 remained outstanding.

The pre admission and assessment process was not robust. Appropriate risk assessments and care plans had not been created for some people who had moved into the service.

Accidents and incidents were recorded and investigated appropriately. However, the provider failed to notify CQC of all safeguarding concerns. This was raised with the manager and notifications to CQC were submitted retrospectively.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider supported people to engage with the local community. For example, some people were part of a local 5 a side football team. The manager was committed to building stronger community links and had proactively created opportunities for people to get involved. As a home, they agreed to support the local foodbank. The manager developed a plan for people to volunteer by shopping for food and delivering it. The manager discussed how they planned to further strengthen community links while continuing to involve people in meaningful ways.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

Governance and quality assurance systems had not demonstrated sustained improvement. Gaps in staff supervisions and appraisals did not assure us staff were supported effectively to develop, and gaps in knowledge and training could be identified.

However, people we spoke to felt involved in decisions about the service and it’s development. This was supported by evidence of resident meetings, focus groups and people’s involvement in staff interviews. Accidents and incidents were reviewed, lessons learned shared with the team, and changes implemented.

An action plan was in place, and the provider was responsive to feedback following our assessment, demonstrating action had already been taken to address most of the concerns raised.