Roberttown Care Home Limited

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

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’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

Although staff carried out regular reviews, care plans did not contain sufficient, person-specific information to guide the delivery of safe and effective care and treatment. Care plans were overly lengthy and included unnecessary content, which made it difficult for staff to quickly locate relevant and current information. In several cases, care plans lacked updates following significant changes in need, such as falls, incidents, or the emergence of specific health conditions, resulting in gaps in the information available to staff.

Clinical assessment tools were in place, including Waterlow scores for monitoring skin integrity and Malnutrition Universal Screening Tool (MUST) assessments for identifying nutritional risks. However, these tools were not consistently updated in response to people’s deteriorating health. For example, although some people had recorded weight loss in their MUST scores, there was no associated care planning to identify required actions, nor was this information integrated into their wider care plans. There was a clear disconnect between clinical assessments and care planning, which limited staff’s ability to deliver responsive and preventative care.

People and their relatives reported that they had not been involved in the development or review of care plans. Comments included, “No, I haven’t seen my care plan,” and “I don’t remember speaking with anyone about my care plan.” This lack of collaboration reduced opportunities to tailor care to individual preferences and ensure that people remained informed and involved in decisions about their support.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

Clinical monitoring tools such as the Malnutrition Universal Screening Tool (MUST) and food and fluid intake charts were in place. However, where people were noted to be declining meals, eating very little, or where chart entries inaccurately stated food had been consumed when it had not, these records were not being routinely reviewed or acted upon by senior staff or managers. This lack of oversight placed people at ongoing risk of unmonitored weight loss and malnutrition.

Care plans did not clearly or accurately reflect people’s current nutritional needs, and there was a lack of clarity for staff on how to respond to concerns related to poor dietary intake.

Staff we spoke with were unaware of who had experienced weight loss. They reported regularly lacking sufficient time to support people adequately at mealtimes, with this responsibility often falling to agency staff. During our observations, agency staff supporting people with meals did not engage meaningfully with them, which could negatively affect the dining experience and discourage nutritional intake.

The failure to monitor, respond to, and act on changes in people’s nutritional needs placed individuals at increased risk of avoidable harm and did not support the delivery of person-centred, safe care.

The provider did not work well across teams and services to support people. They did not share their assessment of people’s needs when people moved between different services.

Most staff told us they did not have time to read people’s care plans or updates, instead relying on verbal handovers from senior staff or management. This limited understanding of people’s current needs and compromised the delivery of safe and consistent care. Staff confirmed that agency workers did not routinely access or read care plans. One staff member reported, “At the minute they [agency staff] are supposed to read the care plans but it’s not quite happening. They are getting thrown in at the deep end. We are talking them through what we can, but we’re sending them off to get people up on their own.”

Internal communication and information-sharing across the team were ineffective. Staff were unaware of key care needs, including recent weight loss or behaviours that challenge. One staff member stated they were not aware of any falls in the previous 2 months, despite records indicating multiple incidents. This failure to communicate key information increased the risk of people receiving unsafe or inconsistent care.

We found no evidence of multidisciplinary team (MDT) meeting records or effective processes to support coordinated partnership working. Care plans were not written in a way that enabled external professionals to easily locate or understand essential information. As a result, external partners faced challenges in accessing relevant clinical data to inform care and treatment.

Where external professionals had made clinical recommendations, such as GPs advising increased monitoring or intervention, these were not consistently recorded, actioned, or communicated to staff. For example, in January 2025, a GP advised that 1 person be weighed weekly due to ongoing weight loss and be referred back to them if deterioration continued. Records showed weekly weights had not been carried out and no referral was made, despite the identified concern. This lack of follow-through placed the individual at ongoing risk of harm.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

While most care records reviewed showed some engagement with external professionals, there was at least 1 instance where a person reported delays in referrals to their GP, despite having made requests for medical input. This raised concerns about the effectiveness and timeliness of access to healthcare support.

There was limited evidence that activities were planned or delivered to promote people’s physical health and well-being. Records of activity provision showed that engagement was largely passive, focusing on music, television, or general conversation. There was minimal evidence of structured or meaningful activities aimed at supporting mobility, rehabilitation, or cognitive stimulation. The activity coordinator was responsible for covering the whole home, which limited their capacity to deliver a varied and person-centred programme. Activity logs between May and June indicated that exercise had been provided on only 1 occasion during that period.

People told us they often had to wait for support and did not feel staff had sufficient time to engage with them meaningfully or support their independence. One person said they rarely had opportunities for personal interaction or stimulation. Staff echoed this concern and expressed a desire to spend more time with people but felt unable to do so due to workload pressures.

Discussions with staff also revealed gaps in knowledge relating to health conditions and associated care needs. When asked, staff were unable to consistently describe appropriate care practices for specific conditions, raising concerns about their ability to provide effective, individualised care and support.

The lack of personalised therapeutic activity, combined with insufficient staff knowledge and poor access to timely clinical input, limited people’s opportunities to maintain or improve their health, independence, and overall quality of life.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

There was limited evidence to demonstrate that the service was meeting people’s clinical or personal expectations. This was due, in part, to a lack of collaborative working with people to establish meaningful goals or outcomes. Care plans did not reflect person-centred objectives or agreed aspirations, and therefore there were no measurable achievements to track progress or evaluate the effectiveness of care. As a result, it was unclear how the service ensured that people’s expectations, both clinical and personal, were being understood or met.

While clinical monitoring tools, such as food and fluid intake charts, were in use, we identified examples where entries were inaccurate. For instance, records indicated that a person had eaten breakfast when they had not consumed any food all morning. These inaccuracies compromised the integrity of the data used to inform care planning and decision-making.

There was no evidence of systematic oversight or audit of these clinical tools by the leadership team. Without effective monitoring, senior staff were not in a position to identify emerging clinical risks or changes in people’s health status. This could have led to unrecognised or unmet needs for some people.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

While initial consent for care tasks was reportedly obtained upon admission to the service, we did not find evidence of ongoing consent processes documented within people’s care records. There was a lack of recorded information regarding named representatives or evidence that representatives were involved in care planning, review, or decision-making. In cases where individuals lacked the capacity to consent, mental capacity assessments were in place; however, these did not demonstrate whether the involvement of appropriate representatives or advocates had been considered or secured.

During the onsite assessment, we observed instances of care being delivered without people being given adequate information or time to provide informed consent. For example, individuals were not routinely offered the opportunity to make or communicate decisions regarding their mobility support. This demonstrated a lack of person-centred practice and did not uphold people’s legal rights to autonomy and informed consent as required under the Mental Capacity Act 2005.