Roberttown Care Home Limited

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 Inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was in legal breach of regulations in relation to safe care and treatment and the safe management of medicines.

This service scored 38 (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 proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events.

The provider did not manage risks effectively. Although staff reported safety related events, including accidents, incidents, and falls, these were not subject to adequate investigation or analysis. As a result, opportunities to identify contributory factors and implement preventative actions were missed. The absence of learning from these events placed people at continued risk of harm and compromised their safety and wellbeing.

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

We reviewed the pre-admission processes for 3 people and requested copies of their pre-assessment records. The provider was unable to supply this documentation. As a result, we were not assured that pre-admission assessments had been completed in accordance with the provider’s own admission policy. This lack of evidence presented a significant risk to people's safety and wellbeing, as it undermined the ability to ensure that admissions were appropriate, safe, and met individual needs.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Some safeguarding referrals were not made in a timely manner to the local authority safeguarding team. This was due to a failure by leadership to review records submitted by staff, which documented new bruises, skin tears, and injuries sustained following falls. This delay in action had the potential to compromise people's safety and did not reflect effective safeguarding oversight. However, prior to this assessment, the interim manager identified these gaps and submitted the relevant safeguarding referrals retrospectively. None of the incidents reviewed were found to have resulted in serious harm or to be indicative of avoidable injury.

Most people told us they felt reasonably safe’ in the service. However, 1 person shared, “At night people come into my room, not care staff, people who live here. I press my buzzer and staff come, eventually.”

We found that the provider had a system in place to monitor and review the use of Deprivation of Liberty Safeguards (DoLS), including oversight of conditions attached to authorisations. Where restrictive practices were in use, such as falls sensor mats, appropriate mental capacity assessments and best interest decisions had been completed in accordance with the Mental Capacity Act.

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

Risk assessments were not sufficiently detailed, lacked person-centred information, and did not provide staff with clear guidance on how to manage and mitigate identified risks. Falls, accidents, incidents, and behaviour monitoring records had not been regularly reviewed or analysed to inform learning or establish preventative action.

Between March and June 2025, five people experienced multiple falls. These recurring events were not reflected in their care plans, and no guidance was provided to staff on how to reduce the likelihood of further incidents. Similarly, incident records showed that 3 people had experienced repeated episodes of behaviours that challenge during the same period. However, there was no evidence of outcomes being recorded, care plans being updated, or strategies being implemented to support staff in managing these behaviours safely and effectively.

Most staff we spoke with were unable to describe how to respond to behaviours that challenge and expressed concern that agency staff, due to lack of familiarity and training, often exacerbated these situations, further increasing risks to people.

In addition, we identified instances where people had experienced unplanned weight loss, yet there was no documented rationale, action plan, or clear guidance for staff on how to meet their nutritional needs. This information had not been communicated effectively across the staff team, as none of the staff we spoke with were aware of which people were affected.

Crucially, important care plans were either missing or not implemented for people with specific risks, including behaviours that challenge, risk of falls, and conditions such as Parkinson’s disease. The absence of these plans limited staff’s ability to provide safe, consistent, and person-centred care and increased the potential for avoidable harm.

The provider has confirmed they have started to make improvements to the care records and risk assessments following our assessment feedback.

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

Environmental checks were largely in place and up to date. The only exception identified was the calibration of weighing scales, which had not been completed at the time of assessment. Calibration of weighing scales ensures the scales are in good working order and provide accurate readings of people’s weight. However, this was promptly addressed, and evidence was seen that the necessary actions had been taken without delay.

Observations of the environment showed that people’s bedrooms were personalised with their own belongings, contributing to a sense of familiarity and comfort. However, several communal areas within the home appeared worn and in need of refurbishment. While dining rooms were small, they were well presented, with tablecloths, menus, and condiments in place to promote a pleasant mealtime experience.

Not all areas of the home were consistently safe. During the onsite assessment, we observed that some door locks were not functioning, and the sluice room door had been left open, which could pose a risk of harm to people, particularly those living with dementia.

There was evidence of dementia-friendly features, such as directional signage to communal areas and colour-coded doors. However, bedroom doors only displayed names and numbers and lacked personal or visual identifiers, which could impact people’s ability, especially those with cognitive impairments, to independently recognise and locate their own rooms, reducing orientation and autonomy.

Actions had been taken following assessment feedback by the provider to rectify the shortfalls identified A service refurbishment plan was put in place ready to be implemented.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Staffing levels had been set by the provider based on people’s assessed needs, with a planned allocation of 5 care staff per shift. However, during the assessment, we observed that 2 out of the 5 staff on duty were agency workers who were unfamiliar with people’s needs and had not read any care plans. Staff reported concerns about the safety and consistency of care under current staffing arrangements. One staff member told us, “We have a lot of agency [staff] who don’t know people and it’s very difficult having to show them and tell them everything they need to do. It makes it harder for us.” Another said, “Yesterday between 7am and 9:30am there were only 2 of us on duty until the agency staff arrived. This was not safe.”

People using the service also raised concerns about staffing levels. A relative told us, “They [staff] are all trying their best, but they don’t all seem to have the experience or training.”

We reviewed induction records for agency staff and found these to be basic, lacking detail on individuals’ needs, preferences, and wishes. There was no evidence that agency staff were provided with adequate time to familiarise themselves with care plans, which posed a risk to the delivery of safe, person-centred care.

Training compliance among permanent staff was low in several key areas. Some staff continued to deliver care despite having out-of-date training flagged as ‘urgent’ on the provider’s training tracker. In addition, prior to assessment there were no clear or consistent records of staff competencies in essential areas such as safe manual handling, use of thickening agents, hand hygiene, or observational spot checks. The current interim manager had begun completing competencies in the days leading up to the assessment.

However, we reviewed 3 recruitment files and found that pre-employment checks had been completed in accordance with safe recruitment practices, including identity verification, references, and Disclosure and Barring Service (DBS) checks.

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.

The service appeared visibly clean throughout and was free from malodours at the time of assessment. Cleaning staff were observed to be diligent in maintaining hygiene standards in both communal areas and individual bedrooms, with daily cleaning schedules adhered to.

Hand hygiene facilities were available and appropriately stocked. Staff demonstrated correct use of personal protective equipment (PPE) and were observed to be bare below the elbows, in line with the service’s Infection Prevention and Control (IPC) policy. These practices contributed to reducing the risk of cross-contamination and promoting a safe environment for people living in the service.

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

When people were prescribed medicines to be taken ‘when required’ (PRN) or with a choice of dose, the protocols to support their administration were not detailed enough to ensure they were administered safely and consistently. When medicines prescribed in this way were administered, staff did not record in a timely manner, that they had checked the medicines had worked.

Some people were not given their medicines safely because staff failed to follow the manufacturers’ directions properly. Other people could not have their medicines as prescribed because there was no stock available in the home. One person was unable to have their prescribed laxatives for 5 days and another person was unable to have their prescribed medicine to treat the symptoms of dementia for 1 day, because the medicines had not been ordered on time. This put people’s health at risk of harm.

When people were prescribed thickener to be added to their drinks, to help them swallow safely, we found there was conflicting information in care plans about how thick their drinks should be made. The records about the use of thickener were variable, some records showed that the drinks had not been thickened correctly or had not been thickened at all, this meant the person was at risk of aspiration and chest infections.

Records about creams did not always show these had been applied safely. There was no information recorded to guide staff as to where to apply the prescribed creams and the staff applying creams did not always make a record to show where they had applied the cream.

Some people did not have details of the medicines they were allergic to recorded on their medicines records charts which meant they were at risk of being given medicines that they had previously had a reaction to.

Checks were made weekly and monthly by managers to ensure medicines were managed safely. However, the checks had not identified all the concerns about medicines and when concerns were identified they had not been resolved, because the same issues were identified in subsequent checks.

We found no evidence that people were harmed at the time of the assessment. However, people were placed at increased risk of harm by not managing medicines safely.