Roche Abbey Care Home

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 requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of the legal regulation in relation to people’s safe care and treatment.

This service scored 47 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Record keeping within the service was poor. Records relating to accidents and incidents were not always shared with appropriate agencies and there was minimal evidence available to demonstrate learning from incidents.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. Records did not always contain important information about people’s needs. This meant that when people moved between services we could not be assured that records would support partner agencies to understand people health and social care requirements.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not 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 share concerns quickly and appropriately. There were a number of safeguarding concerns under investigation at the time of our inspection, and the service had been placed into organisational safeguarding by local commissioners. We found that while the service did make safeguarding referrals into the Local Authority, it did not always share this information with CQC as required. There was also a lack or consistent analysis of themes and trends regarding safeguarding events.
People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that the service was not working in line with the principles of the act. Records relating to DoLS were incomplete and we could not be assured that conditions relating to people’s DoLS were incorporated into people’s care plans or followed by staff.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Care staff were not always supported to care for people in line with their preferences as care plans did not always contain person centred information about their preferences for support. There was not always evidence that information within plans was followed. For example, 1 person’s care plans stated they should be offered the opportunity to leave their bed every day, daily care notes did not evidence that this was happening.

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. The provider had not ensured environmental risks within the service were managed safely. A cupboard containing an electrical box should have been locked and was found to be open. An area of the service which was out of use contained multiple pieces of furniture, equipment and items on the floor which posed a trip hazard to people, this area was not locked or secured. One bathroom had exposed pipes which were hot to the touch and posed a burns risk to people, the bathroom was very hot and people and staff would not have been able to use this room comfortably. Some people did not have call bells to summon help when needed despite care plans stating these should be in place. Leadership at the service had not ensured roles and responsibilities in relation to ongoing maintenance at the service were clear. Some maintenance certificates could not be located during the assessment. The provider took immediate steps to rectify the issues found during the inspection including confirmation of fire safety checks and risk assessments having been carried out.

The provider did not always 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 always work together well to provide safe care that met people’s individual needs. The provider had failed to deploy sufficient staff to meet the needs of people effectively. The provider had used a dependency tool to calculate the numbers of staff needed but had failed to ensure the correct information about people’s needs was added. Concerns raised by staff regarding staffing levels had not been actioned. We found evidence in records that people had had to wait for long periods of time to have basic needs such as continence care provided. The provider took immediate steps to address levels of staffing and strengthen leadership within the home. These improvements require embedding into practice.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. Infection prevention and control measures required some improvement. We found that some equipment used by people was in poor condition with damaged surface areas. This created a risk as these areas cannot be cleaned effectively. The inside of cupboards were not always clean and unlabelled and undated foods were found inside fridges.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. Protocols for people’s ‘as and when’ required pain relief medication were not always in place to ensure staff knew how and when to give these medicines safely. A person was given a product to thicken their drinks which was prescribed for another resident, prescribed items should not be shared. We found that topical creams and eye drops prescribed to people were not always dated once opened to ensure these were disposed of in line with the manufacturer’s instructions. Care plans relating to the management of oxygen lacked detail and specific risks to individuals.