Roche Abbey Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question inadequate. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. 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.

The provider had inclusive leaders who understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge, and experience to lead effectively. They did so with integrity, openness and honesty. The manager was in the process of registering with the Care Quality Commission. The manager was supported by a deputy manager and a team of nurses and senor care workers. Support was provided to the management team by the area manager who visited the home weekly. We received mixed comments about the management team from people and relatives. One relative said, “I am happy with the care [family member received]. I think it [the home] is well run and has recently improved.” Another relative said, “It [the home] could be better run. I have never been introduced to the manager, but I know who they are. I am not sure if they are approachable.” We raised these comments with the management team who told us they were introducing new systems and processes to ensure people were more involved.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a whistle blowing policy and staff were supported to raise concerns and the manager was keen to listen to people and make changes. Staff were confident the management team would take appropriate actions swiftly to ensure people were protected from harm.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The manager told us all staff at Roche Abbey had been employed based on their skills, qualifications, and passion for healthcare. The manager said, “We have staff members that have returned from maternity leave who are given protected time when required and we also remain flexible with working hours for those with young children. We also take into account staff religion and would always make accommodations for those who required protected prayer or mealtimes.” Some staff had been supported to change their job roles due to health issues, helping them to continue working at Roche Abbey. Adaptations had been put in place to consider different staff learning styles, so they could complete their mandatory training effectively.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. Audits were in place to show oversight of the home. However, some audits required further embedding to ensure they identify all areas of improvement. Since our last assessment the manager had implemented daily walk rounds to have a presence on the unts and to ensure staff were carrying out their role in line with the standards expected from the provider. Staff meetings had taken place and showed input from staff. Whilst the provider had taken action to address the concerns raised during previous assessments, we need to see that new systems and processes are fully implemented, embedded and maintained.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The manager told us they had good relationships with other professionals involved in people’s care. This included commissioners, district nursing team, and the GP service, who undertook weekly ward rounds.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. The management team were working towards completing a programme of refurbishment. This included 1 of the lounge areas downstairs. This will offer people more areas to sit downstairs and hopefully be more conducive to socialising.