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 good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of the legal regulation in relation to good governance.

This service scored 36 (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 have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities. The provider had not been proactive in supporting staff at the service to complete their roles to a high standard. The provider had failed to ensure adequate oversight of the service was taking place and had not identified and addressed concerns regarding ensuring enough staff were deployed to meet people’s needs.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. We could not be assured that concerns were always managed effectively or referrals made to partner organisations as required. The provider took action to improve leadership within the service during the inspection. Improvements from this action will take time to embed into practice.

People did not always feel they could speak up and that their voice would be heard. Feedback was mixed from staff and relatives regarding speaking up. Some staff told us that concerns they raised regarding personal matters were managed well and they felt supported, however concerns regarding staffing were not acted upon or listened to.

The provider did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. Not all staff felt supported or listened to at the service. We were not assured members of staff were supported effectively to deliver good quality care and support to people.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Governance systems were poor and ineffective. We could not be assured that referrals about risk were made to partner agencies as they should be and accidents and incidents were not consistently analysed to support improvement and mitigate future risks to people. Roles and responsibilities were not clear within the leadership of the organisation. The provider had not ensured robust oversight of the service was taking place and had failed to identify and address concerns relating to insufficient staffing levels, poor record keeping and a lack of person-centred care. The provider did act to increase both leadership and staffing once concerns were brought to their attention. We could not be assured that proactive systems were embedded to ensure concerns would be addressed without the support of partner agencies.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. We found referrals to partner agencies were not always made, this included referrals to CQC regarding safeguarding incidents. Where professionals had given advice to support people’s health needs this information was not always recorded in people’s plans or followed by staff. We could not be assured that work to identify and address risk was taking place.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. There was no evidence of a learning culture within the organisation. The provider had not ensured effective oversight of the service was taking place. Although some tasks were marked as having taken place, for example care plan audits, these had not identified or addressed deficiencies in record keeping. As governance processes were ineffective the provider did not have a full understanding of which areas of the service needed to be addressed. The provider took some early actions to increase leadership and oversight of the service. It will take time to embed these changes and for the provider to plan and implement improvements.