Roche Abbey Care Home

Updated 22 July 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by 2 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Roche Abbey is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Roche Abbey is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 5 people who used the service and 7 relatives about their experience of the care provided. We spoke with 10 members of staff including the registered manager, deputy, nurses, care workers and ancillary staff. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included 5 people’s care records, multiple medication records, staff files in relation to recruitment and staff supervision and quality monitoring records.

Updated 22 July 2023

About the service

Roche Abbey is a residential care home providing personal and nursing care for up to 67 people. At the time of our inspection there were 37 people living at the home. Some people using the service were living with dementia.

People’s experience of using this service and what we found

There were quality monitoring systems in place. However, these were not always effective. Some areas for improvement we identified during the site visit were not identified as part of the providers quality monitoring systems. For example, infection control shortfalls and management of risk. We identified risks in relation to people's nutrition and weight loss were not managed effectively.

We have made a recommendation about the management of risks.

We found enough staff on duty on the day of our site visit. The registered manager used a dependency tool to determine staffing levels and we saw this was followed. However, we observed staff could be task orientated with set times for specific support, rather than care being person-centred.

The home generally, was visibly clean. However, we found some areas that were not clean. Mattresses, pressure cushions and chairs were stained and dirty and kitchenettes required a thorough clean. The registered manager confirmed action had been taken following our inspection.

People received medication as prescribed. Staff received training and competency assessments. However, we identified some minor documentation issues that had not been picked up by the audit systems. These were addressed by the registered manager following our site visit.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Staff were aware of what actions to take to safeguard people from the risk of abuse. The manager kept a record of safeguarding concerns and monitored the outcome. Accidents and incidents were analysed and evidence to show what actions had been taken to mitigate future incidents.

People and relatives spoke highly of the registered manager and felt she was approachable and listened to any concerns or issues raised. Most staff told us they worked well as a team and were supported, however, some felt the registered manager could be more visible on the units.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published February 2022). The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections

Why we inspected

This was a planned inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

This was a focused inspection. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Roche Abbey on our website at www.cqc.org.uk.

Enforcement

We have identified a breach in relation to governance and leadership.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.