CQC report explained · a nursing home
What the CQC found at Roche Abbey Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, July 2023
Rated Requires Improvement; inspectors found safety and leadership shortfalls, including a breach of governance requirements.
This was an unannounced focused inspection in June 2023. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicine, recruitment and monitoring records.
The home had enough staff on duty on the inspection days, medicines were generally given as prescribed, and people said they felt safe. Staff understood safeguarding procedures, and accidents and incidents were reviewed.
However, risks linked to weight loss were not managed or recorded well enough. Some mattresses, chairs and pressure cushions were dirty, and medicine records had minor gaps. Care could also be task-led rather than centred on each person's preferences.
The home was rated Requires Improvement overall, with Safe and Well-led also rated Requires Improvement. This was unchanged from the previous inspection and was the third consecutive inspection with this overall rating.
Staffing and recruitment
Inspectors found enough suitably trained staff on duty during the visit. Recruitment checks were in place.
“There were enough suitable trained staff to meet the needs of the service.” from the report
Safeguarding
Staff knew how to respond to possible abuse. Safeguarding concerns were recorded and reported to the safeguarding authority.
“People we spoke with told us they felt safe living at the home.” from the report
Choice and legal safeguards
People's choices were respected, and the report found that the home was working within the principles of the Mental Capacity Act.
“People told us they were supported to make decisions and their choices were respected.” from the report
Approachable management
People and relatives spoke positively about the registered manager and said concerns were listened to and followed up.
“People and relatives spoke highly of the registered manager and felt she was approachable and listened to any concerns or issues raised.” from the report
Weight loss risks
seriousSome people had lost considerable weight, but care plans did not explain clearly enough how this risk should be managed. Reviews and actions were not recorded properly.
“People had lost considerable weight, the care plans and supporting documentation did not give details of how to manage this.” from the report
Weak quality checks
seriousThe home's audits did not identify several problems found during the inspection. This led to a breach of Regulation 17.
“The provider had failed to ensure governance systems were effective. This is a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Cleanliness
needs fixingThe home was generally visibly clean, but some mattresses, chairs, pressure cushions and kitchenettes needed a thorough clean.
“We found soiled seat cushions and mattresses and kitchenettes required a thorough clean.” from the report
Mealtime support
needs fixingInspectors saw people being given meals and then left while staff served others. Some people were not encouraged to eat or offered suitable food if they would not sit at a table.
“People did not always receive person-centred care. We observed the dining experience could be improved.” from the report
Medicine records
minorPeople received medicines as prescribed, but some records did not show carried-over amounts or that topical medicines had been applied. The manager addressed this after the inspection.
“However, we found some minor documentation issues.” from the report
- 01What has changed in the way you identify and manage weight loss, and how do you check that care plans are being reviewed?
- 02What cleaning checks are now in place for mattresses, pressure cushions, chairs and kitchenettes?
- 03How do you make sure there are enough staff and good staff deployment at weekends and during mealtimes?
- 04How are medicine records checked to confirm topical medicines are applied and carried-over amounts are recorded?
- 05What action has been taken to meet Regulation 17, and what evidence can you show that the new monitoring systems are working?
This was a focused inspection of Safe and Well-led; the other key-question ratings were not inspected and the previous ratings were used to calculate the overall rating. This explanation was written from the published report of 22 July 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, February 2022
Rated Requires Improvement; inspectors found kind, responsive care, but medicines, risk checks and management oversight were not always reliable.
This was an unannounced inspection on 17 January 2022. The inspectors spoke with four people living in the home, 13 relatives and 10 staff. They also checked care records, medicines, staffing, infection control and management systems.
People told inspectors they felt safe and were treated kindly. Staff were recruited safely, staffing levels were judged sufficient, the home was clean, and infection control arrangements were effective. Care plans supported people's needs, and people had access to healthcare and activities.
The home still needed to improve how it managed medicines and risks, including weighing people as often as their care plans required. Audits were irregular and did not always find these problems. The home was in breach of Regulation 17, relating to good governance.
The overall rating was Requires Improvement. Effective, Caring and Responsive were rated Good. Safe and Well-led remained Requires Improvement. The previous inspection also rated the home Requires Improvement, although Effective and Responsive improved from Requires Improvement to Good.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw warm interactions and found that privacy, dignity and independence were protected.
“People told us they continued to receive kind and compassionate care. We observed warm interactions between people and staff.” from the report
Person-centred care plans
Care records described people's needs, preferences, communication and backgrounds. Staff used this information to provide individual support.
“Care plans were person centred and detailed people's likes and dislikes and how they wanted to receive support.” from the report
Safe staffing and recruitment
Inspectors found enough staff to support people safely and saw staff respond to people's needs in a timely way. Pre-employment checks were completed.
“There were enough staff to support people safely. Staff had a positive approach to supporting people and we observed staff responded to people's needs in a timely manner when required.” from the report
Good food and healthcare support
People liked the food and were offered choices. Staff worked with healthcare professionals when needed, and records reflected current care requirements.
“People were offered choices for their meals and liked the food.” from the report
Weak management checks
seriousAudits did not always identify problems with medicines or weighing people, and some audits were not completed as often as planned. This led to a breach of Regulation 17.
“There was not an effective quality assurance system in place to identify shortfalls and act on them to ensure people were safe.” from the report
Medicine records
needs fixingSome liquid and cream medicines did not have an opened-on date, and some handwritten entries did not follow best practice. Inspectors said this did not place people at significant risk, but the audit had not found it.
“Some liquid and cream medicines did not have an opened-on date and not all handwritten entries were recorded following best practice.” from the report
Risk monitoring
needs fixingRisks were documented, but people were not always weighed at the frequency set out in their assessments. Further improvement was needed and had to be sustained.
“At this inspection risks were documented appropriately, however, further improvements need to be made and sustained.” from the report
Limited formal feedback
minorPeople and relatives were not always asked for their views regularly through formal surveys. Some feedback had not been followed up, and one questionnaire was difficult to read.
“Seven of the 13 relatives we spoke with told us they had not received a survey or questionnaire from the service.” from the report
- 01How are you now checking that medicines are recorded correctly, including opened-on dates and handwritten entries?
- 02How often are people weighed, and how do you check that this matches their care plans?
- 03What changes have you made to your quality audits since this inspection, and how do you know they find problems promptly?
- 04How do you gather relatives' views regularly, and how do you respond to suggestions or complaints?
- 05What progress has been made on the action plan requested by CQC?
This was an unannounced inspection covering all five key questions, with particular checks on infection prevention and control and COVID-19 preparedness. This explanation was written from the published report of 17 February 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Roche Abbey Care Home
3 rated inspections over 2 years: the service has held its Requires improvement rating throughout.
- July 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- February 2021Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2020
Registered with the Care Quality Commission on 11 March 2020.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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