The Care Quality Commission
  • Care Home
  • Care home

Roche Abbey Care Home

Overall: Requires improvement read more about inspection ratings

Millard Lane, Maltby, Rotherham, South Yorkshire, S66 7LZ

Provided and run by:
East And West Healthcare Limited

Important:

We served a warning notice to East and West Healthcare Limited on 30 September 2026 for failing to ensure safe care and treatment and good governance practices were in place at Roche Abbey Care Home.

All Inspections

During an assessment under our new approach

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.

During an assessment under our new approach

Date of Assessment: 4 August to 12 August 2025. The service is a residential care home providing personal and nursing care to older people and young adults. Some people were living with dementia. We carried out this assessment to check the service had continued to sustain improvements.

 

The provider had a good learning culture and people could raise concerns. The management team investigated incidents thoroughly. Risks associated with people’s care were identified and managed to keep people safe. The facilities and equipment met people’s needs, were mainly clean and well-maintained. However, some areas required deep cleaning, some fire doors required replacement, and 2 rooms were without window restrictors. These issues were acted upon and have now been resolved. There were enough staff with the right skills, qualifications and experience. The management team made sure staff received training and regular appraisals to maintain high-quality care. People received their medicines as prescribed by staff who were trained and supported to administer them safely.

 

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. People had enough to eat and drink to stay healthy and had access to nutrition and hydration which met their needs. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. They monitored people’s health to support healthy living. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people and took decisions in people’s best interests where they did not have capacity.

 

People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and were encouraged to maintain relationships with family and friends. Staff responded to people in a timely way. The provider supported staff wellbeing.

 

People were involved in decisions about their care. Staff provided information people could understand. People knew how to give feedback and were confident the provider took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. Staff worked to reduce health and care inequalities through training and feedback.

 

The management team and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. The management team worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.

 

During an assessment under our new approach

Roche Abbey is a care home providing personal and nursing care for up to 67 people. Some people were living with dementia. At the time of our inspection there were 33 people using the service. We carried out our on-site assessment on 4 November 2024. The purpose of the assessment was to check progress since our last assessment where we found 4 breaches of regulation, and a warning notice was served. We looked at some quality statements in Safe and Well-Led, including involving people to manage risks, infection prevention and control, medicine optimisation and governance, management and sustainability. Since our last inspection the service had improved and were meeting the requirements of the warning notice and had met all the previous breaches.

During an assessment under our new approach

Roche Abbey is a care home providing accommodation for people who require personal and nursing care. Some people were living with dementia. The service can support up to 67 people. At the time of our assessment there were 36 people living at Roche Abbey. This assessment was triggered by concerns we received about the service and commenced with a site visit on 13 May 2024 and ended on the 29 May 2024. During this time, we reviewed documents on and off site and communicated with staff, leaders, and visiting professionals. We assessed a total of 17 quality statements from the safe, caring, responsive and well-led key questions and found areas of concern. The scores for these areas have been combined with scores based on the key question ratings from the last inspection. The last rated inspection under our previous methodology was published on 22 July 2023 and was rated requires improvement overall. Since our last inspection the service has deteriorated further. We found 4 breaches in regulation relating to person centred care, safe care and treatment, fit and proper persons employed and good governance. At the time of our inspection there was no registered manager in post. The home had been without a registered manager since November 2023. There was no stable management team in place, and this had created lack of leadership. Systems had been effective in identifying some concerns we found during this assessment. We have asked the provider for an action plan in response to the concerns found at this assessment. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.

9 June 2023

During an inspection looking at part of the service

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.

17 January 2022

During a routine inspection

About the service:

Roche Abbey Care Home is a residential nursing home providing accommodation, personal care and treatment of disease, disorder or injury for 31 people, at the time of the inspection. The service is a three-floor building. Each floor has separate adapted facilities.

Management oversight at the service was not always effective. We found audits were irregular and did not always identify issues at the service which required attention. People living at the service and staff had confidence in the manager, and the service worked well with other professionals to improve people's care.

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

Although some improvements had been made since our last inspection, continued improvement is required to the management of people’s medicines and the management of the risks identified to some people. People told us they felt safe living at Roche Abbey. Staff were recruited safely and there were sufficient staff on duty to deliver person-centred care. The home was clean and had safe infection prevention and control practices and procedures in place.

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 working at the service received regular supervision. People we spoke to told us they enjoyed the food at Roche Abbey. People's needs had been assessed before they moved to Roche Abbey and people had access to healthcare professionals when required.

People spoke positively about living at Roche Abbey and liked the staff who supported them. People were treated kindly and had their privacy and dignity protected.

Care plans and other documents detailed people's care needs, and staff used these to provide people with the right care and support. People were able to do the things they enjoyed and were supported to have contact with people who were important to them.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 3 February 2021) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made/sustained and the provider was still in breach of regulations.

Why we inspected

We carried out this inspection following a routine review of information we held about this service.

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.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified a breach in relation to good governance. You can see what action we have asked the provider to take at the end of this full report.

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

7 January 2021

During a routine inspection

About the service

Roche Abbey is a care home providing personal care and nursing. It can accommodate up to 67 people. Some people using the service were living with dementia. There were 22 people using the service at the time of the inspection.

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

The service had recently had a change in management. There was no registered manager however, the provider had appointed a new manager who was registering with the Care Quality Commission (CQC). We found systems and processes used to ensure the service was running safely had not been followed so were not robust or effective. The information in audits was inconsistent and, in some cases, not completed, therefore they were not able to be effectively reviewed to drive improvements.

People were not always safe. Risks were not managed to ensure people’s needs were met and safety maintained. Medication procedures were not always followed to ensure people received their medicines as prescribed. We identified shortfalls in the way people’s medicines were managed. People were not always protected by the risk and spread of infection. The environment was not clean, we found areas of the home had malodours and were not thoroughly cleaned. We were not assured by the infection control systems in place. However, the manager has actioned this following our inspection.

There were predominantly adequate staff on duty on the day of our inspection and staff said there was mostly enough staff to meet people’s needs. However, there was no effective dependency tool in place to ensure staff were deployed effectively to ensure people’s needs were met. Staff had not consistently received specific training to meet people’s needs.

People were supported to have maximum choice and control of their lives and we observed staff supported them in the least restrictive way possible and in their best interests. However, this was not reflected in people’s care plans. Care plans were not personalised, difficult to follow and did not detail people’s current needs. Peoples preferences were not always recorded, this included people who were receiving end of life care.

The provider had a recruitment process in place which showed staff were recruited safely. However, we found not all checks required were carried out. Safety checks were carried out. However, we found not all checks were carried out in line with the policy.

The staff team worked together with external agencies to deliver effective care and treatment and support people’s access to healthcare services. However, this was not always clearly documented to show actions taken.

Staff felt supported and spoke highly of the clinical lead. However, they were not formally supervised. Staff felt there had been lack of leadership and direction but felt more confident the home was now in a better place to move forward.

There were systems in place to safeguard people from abuse.

Staff supported people appropriately. Their approach was kind, caring and person-centred. Staff respected people’s privacy and dignity. People and relatives, we spoke with, praised the care staff and could not fault the care they provided.

The new manager had identified many of the shortfalls since their appointment and told us improved quality monitoring was being devised to ensure issues were resolved and to drive improvements.

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

Rating at last inspection

This service was registered with us on 11/03/2020 and this is the first inspection.

The last rating for the service under the previous provider was Inadequate, published on 19 July 2018.

Why we inspected

The inspection was prompted due to concerns received from the local authority commissioners. These were regarding, staffing and lack of robust infection prevention and control. There had also been an outbreak of COVID-19 in the home. As a result, we undertook an inspection looking at all five key questions.

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 coronavirus and other infection outbreaks effectively.

The overall rating for the service is requires Improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see all sections of this full report.

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 Cambron House on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and treatment and leadership and oversight at this inspection.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.