Updated 16 September 2026
Date of assessment: 17 September to 24 September 2026. We visited the service on 17 September and 23 September 2026 and spent time observing people’s care and reviewing records and information. Roche Abbey Care Home is a nursing home which provides personal and nursing care to adults, some of whom were living with dementia or physical disabilities. Up to 67 people can reside at the service. At the time of our assessment 52 people were living at the service. This assessment was undertaken due to concerns received about the service. The assessment was comprehensive, which meant we looked at the 5 key questions of safe, effective, caring, responsive and well-led. The service was previously rated good. At this assessment, the service was rated requires improvement.
We found there were insufficient numbers of staff present to meet people’s needs effectively or to deliver person-centred care. Information and advice from professionals were not always incorporated in people’s plans of care or followed by staff. We found that some people had to wait for long periods of time for their continence care needs to be met and important interventions such as repositioning to support people’s skin viability was not completed at regular intervals as agreed. We could not be assured that reports of potential harm had consistently been shared with the correct agencies and record keeping at the service was poor.
People’s health needs were not always effectively assessed, addressed and monitored. Information and advice from professionals were sought but was not used effectively to support people. [SL1.1]Staff were not supported by a strong leadership team that enabled them to work to the best of their abilities. Most staff told us they liked their jobs but did not feel listened to when raising concerns.
Leadership at the service was poor. Recording keeping and governance was ineffective and had not identified and addressed concerns early. There was a lack of provider oversight to ensure the service was managed appropriately and this resulted in a deterioration in the quality of care and support on offer at the service. The provider took some early steps to address the concerns we brought to their attention. This included deploying additional staff and leadership at the service. Early feedback from staff regarding these improvements was positive.