Roberttown Care Home Limited

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Inadequate. This meant services were not planned or delivered in ways that met people’s needs.

The provider was in legal breach of regulations in relation to person centred care.

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 make sure people were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

The service did not provide care that was person-centred, and this had a significant negative impact on people’s experiences and wellbeing. We found that care was often task-driven rather than tailored to individuals’ needs, preferences, or routines. Care records failed to show people were involved in making decisions about their care, and people and relatives confirmed they had no involvement in the care plan review process.

Care plans lacked personalised detail and did not reflect people’s life histories, interests, or cultural needs. As a result, staff did not always know how best to support individuals or respond in a way that was meaningful and respectful. For example, one person who enjoyed sitting at the table for lunch with others on the day of assessment was left sitting in a chair in the lounge for lunch. Some people remained in their rooms although their care plans stated they enjoyed social interaction and joining in with activities, but no efforts had been made to engage them in activities or adapt activities to their needs.

Staff told us they did not always have time or direction to deliver care in a person-centred way. Most staff told us, “We don’t get time to read care plans, we get to know the residents’ needs from what the seniors tell us.”

There were significant shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not joined-up, flexible or supportive of choice and continuity.

People told us they felt they did not always receive the care and treatment they paid for. Several people told us they did not feel supported in a way that met their individual needs, with some describing limited meaningful interaction with staff and a lack of engagement. One person commented, “There’s no time for proper conversation, they’re always rushing off.” Others reported long wait times for assistance, including delays in accessing external professionals they had requested, such as GPs. This had a direct impact on people’s health and wellbeing, as essential support was not always provided in a timely or person-centred manner.

The provision of activities was limited and did not consistently reflect the diverse needs, interests or preferences of the people using the service. As a result, people told us they often felt bored, isolated or not meaningfully occupied, which impacted their quality of life. For example, there was little evidence of tailored activities for people living with dementia or those who required more sensory or stimulating engagement.

Staff did not demonstrate a sufficient understanding of the complex health and social care needs of the service user group, particularly in relation to dementia care and behaviours that challenge. We found no evidence of targeted or updated training to equip staff with the knowledge and skills needed to support people safely and effectively. This meant some people were not being supported in ways that were appropriate or responsive to their needs, potentially increasing the risk of distress or disengagement.

The provider did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

People did not always receive information in a way that supported their understanding or involvement in their own care. Several individuals told us they had not seen their care plans and were not involved in their ongoing reviews. This limited their ability to participate meaningfully in decisions about their care. Feedback from relatives was mixed, with some reporting an awareness that care plans existed, while others said they had never been shown them.

We found no evidence that care documentation was made available in alternative formats or that people or their relatives had been consulted about such options. There was no indication that large print, pictorial, or easy-read versions of care plans had been offered or discussed. Furthermore, we did not see any mechanisms in place to support people or relatives in routinely accessing or receiving copies of up-to-date care plans.

Although kitchen staff told us that pictorial menus were available to support communication around meal choices, these were not used on the day of inspection to promote informed choice for people using the service. The menu displayed on the table was in a larger font, which may have supported accessibility for some, but this did not constitute a consistent or inclusive approach to meeting communication needs.

The service did not demonstrate that it effectively listened to or acted on the views, concerns, or feedback of people using the service, their relatives, or staff.

People and their families provided mixed feedback about whether they felt involved in how the service was run. Several relatives told us they had not been invited to meetings, and others said updates were only shared through social media platforms. This limited people's opportunities to express their views in a meaningful and accessible way.

People told us meetings did not take place. One person stated, “They don’t like us having our views and opinions, they don’t want to listen to us.” We were not provided with any meeting minutes involving residents, relatives, or staff, and no resident or relative surveys had been carried out. There was no evidence of how feedback, where it had been collected, was analysed or used to inform improvements in care delivery.

Some people and relatives told us they had raised concerns that had not been acknowledged or addressed by the provider. For example, 1 person told us their relative had raised multiple complaints, including as recently as a few days before our visit. The relative confirmed this and told us they had informed the provider “It’s not good enough,” in reference to the care being provided. The relative had raised concerns around the length of time staff took to respond to call bells but reported no improvements had been made.

Staff engagement was also lacking. An employee engagement form from January 2025 showed that only 2 staff members, a senior carer and a nurse, had submitted feedback. There was no indication that the provider had followed up on the low response or taken further steps to understand or address staff concerns.

In addition, no complaintswere recorded on the provider’s system despite clear evidence from people and relatives that concerns had been raised. This highlighted a significant breakdown in the service’s ability to capture and act on feedback. As a result, people’s voices were not being heard, and concerns were not being used as a tool for learning or improvement.

The provider did not always make sure that people could access the care, support and treatment they needed when they needed it.

People were able to access support in emergencies, and we saw evidence of sensor mat alarms being used appropriately to alert staff to potential risks. Records also showed involvement of emergency services where needed, supporting prompt responses in urgent situations.

However, we found systems and processes for out-of-hours or on-call arrangements were not clearly established. Prior to the manager leaving, there was no formal on-call procedure in place, and this was not reflected on staff rotas. As a result, staff were unclear about who to contact in the absence of the manager, for example during periods of sickness or annual leave. Most staff told us they would speak to the senior on duty, but this informal approach created potential risks in situations requiring leadership or escalation out of hours.

Access to healthcare professionals was variable. While care records showed that some people had involvement from external professionals such as GPs and district nurses, people gave mixed feedback about the timeliness and reliability of this support. One person told us they had repeatedly asked to see a GP and was informed the GP was no longer attending the service. They stated they had been asking for help for several months before eventually being seen. This delay suggested some people did not consistently receive the professional healthcare input they required when they needed it.

Other people told us they were regularly seen by external professionals due to their health conditions, and this was reflected in their care documentation.

While there was some evidence of effective access, inconsistencies in healthcare engagement and the lack of clear emergency cover arrangements meant that not all people had equitable access to timely and appropriate support.

Staff and leaders did not listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not tailored in response to this.

Staff rotas did not consistently demonstrate a suitable mix of skills and experience to meet the assessed needs of all people using the service. This meant some individuals, particularly those with higher support needs, did not consistently receive appropriate or responsive care.

People with protected characteristics or complex health conditions, such as Parkinson’s disease, dementia, or those receiving end of life care, did not always have their needs promoted or appropriately documented. One person’s care plan did not reference important aspects of their cultural or spiritual beliefs, indicating a lack of attention to individual identity, values, and person-centred planning. This omission risked care being delivered in ways that did not respect individuals' values and rights.

Our observations and feedback from some people highlighted that those living with dementia experienced poorer quality care than others. This was reflected in how they were spoken about, treated, and documented by staff. For example, 1 person’s incident record included concerning comments by staff such as: ‘making lies about staff,’ ‘making allegations about staff,’ and ‘keep pressing buzzer for no reason.’ These entries lacked any professional context or clinical explanation and failed to acknowledge the person’s changing condition or potential cognitive decline. Such language suggests a lack of understanding, empathy, and training in supporting people with dementia.

There was no evidence of action taken to understand the underlying causes of such behaviours or to ensure these individuals were treated with dignity and compassion. This contributed to a clear disparity in care experiences between people with complex needs and others. Overall, the service did not deliver equitable care. People’s protected characteristics and individual differences were not consistently identified, respected, or met, leading to discriminatory practice and significant shortfalls in inclusive, respectful care.

People were not supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

The service did not demonstrate safe or person-centred planning for people approaching the end of their life. At the time of inspection, 1 person was identified as receiving end of life care. However, their care plan lacked essential information. It did not contain sufficient detail or guidance for staff on how to meet the person’s needs, nor did it reflect their personal wishes, preferences, or how they wished to be supported during or after death. This presented a significant risk of care being delivered in ways that were not aligned with the person’s values or choices at such a critical time.

Not all staff we spoke with were aware that the person was on end of life care. Several staff members told us, “No, we don’t have anyone on end of life care,” which raised serious concerns about communication and care oversight.

Although all staff told us they had completed a one-day online training course in end of life care, many were unable to describe what high-quality end of life care should look like. Most could not articulate the person’s individual wishes or how to provide the emotional, spiritual, and practical support that would ensure comfort, dignity, and respect.

The lack of clear documentation, staff awareness, and effective training meant the service failed to ensure future care was planned in a way that respected and supported the individual’s needs, both during their final stages of life and after death.