Rock House

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

This is the first assessment for this newly registered service, since the provider changed legal entities. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm. This meant some aspects of the service were not always safe and there was limited assurance about safety. The service was in breach of legal regulations in relation to safe care and treatment and safeguarding people. There was an increased risk that people could be harmed. Significant risks to people had not been sufficiently mitigated. Similar incidents of concern occurred without care plans and risk assessments being updated and robust guidance put in place for staff to follow. We asked the provider to implement some risk assessments as a priority due to the level of concern. Medicines were not consistently managed safely, and risks to the environment had not been mitigated.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Systems to ensure that lessons were learnt and to mitigate known risks were not robust or effective. Incidents had not always been documented to ensure that actions were taken to address known risks. This included significant incidents where people had suffered harm. When incidents were recorded, they were reviewed individually, however there was not always evidence that care plans and risk assessments were reviewed and updated to ensure they reflected the person’s current needs. There was no system in place to review incidents for the whole service to look for trends and patterns. We discussed this with the registered manager who told us they were planning on implementing a system to review incidents as a whole.

Staff made appropriate referrals to healthcare professionals for example therapists, psychiatrists or the community mental health team. However, staff did not always document actions taken to support people who consistently disengaged with support services. It was not clearly documented why people often refused to engage with support services, or actions taken by staff to engage people in this support. We spoke with the registered manager, who accepted this was not well documented, and told us they would address this with staff.

For people with a learning disability or autism, there was no information about what a ‘good’ day looked like or understanding what caused people to have distress or disengage with services.

There were a lack of effective systems, processes and practices to make sure people were protected from abuse and neglect. When safeguarding incidents occurred, they were not always documented or shared with the local authority safeguarding team, which meant that stakeholders were not always aware of incidents of concern. This included significant incidents of self-harm. As incidents were not documented we could not be assured that appropriate action had been taken to address and mitigate the risk to people.

The providers safeguarding log only documented 2 safeguarding incidents for 2024, which was not reflective of incident logs we reviewed, or feedback from staff. The registered manager told us they were going to review and improve the safeguarding log to ensure that all incidents were documented, and was clear what action had been taken to address concerns. Incident documents we reviewed demonstrated that similar incidents re-occurred without clear actions taken to address or minimise concerns by the provider.

Risks to people were not well managed or mitigated. Some people could cause harm to themselves. There was no robust guidance to inform staff on what actions to take should there be concerns about people. Some significant incidents had re-occurred but action to ensure that guidance was reviewed, and updated was not completed. This included risks to self-harm through burns or scalds and attempts at ligatures. This placed people at significant risk of re-occurring harm. We asked the provider to urgently implement risk assessments to inform staff how to safely support people who had attempted self harm using a ligature. On the second day of our assessment, risk assessments were in place, however still needed to be specific to the person. For example, there was mixed information about ligature cutters, where these were located and where they were stored. On the second day of our assessment all staff were issued with ligature cutters.

Staff told us they struggled to support people with complex needs. One staff member told us, “Their needs are great, their mental health needs are very great, with the best will in the world we struggle.”

We were not assured that the environment was always safe and that risk assessments were always in place and mitigating the risk. Throughout the service radiators were unguarded. Although the provider had risk assessed the unguarded radiators, they were very hot to touch and posed a significant burn risk to anyone who fell or sat against them. We raised this with the registered manager and on the second day of our assessment the radiators had been turned down.

On the first day of our assessment, the provider was in the process of installing a new boiler, which meant some rooms had temporary radiators in place. Whilst there was a risk assessment in place for this, we saw in one person’s room risks were not being mitigated. The portable radiator was positioned on top of another radiator, not on a flat surface and not away from flammable sources.



There were no effective arrangements to monitor the safety of the service. The provider and registered manager had not assessed the environment to ensure that ligature points had been assessed and mitigated.

The service 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.

Rotas demonstrated that there was not always the assessed number of staff on duty. When there were occasions, seniors and the registered manager were able to support staff, and leaders told us people continued to receive the support they needed. However, staff told us when people’s mental health declined they needed increased support, which staff were not always able to give them. Staff told us about supporting one person, “It’s a struggle for their mental health, if they don’t get 24/7 attention they go down, we have 14 other people, we try really hard.”

Staff had been recruited through safe recruitment practices. Most staff had completed online training for ligatures, and all staff who had not completed face to face training had a course booked imminently. We discussed this with the registered manager, and they ensured all staff completed online training, and discussed the newly implemented risk assessments with all staff. A relative told us, “I think they know what people are like and what they need, that’s really important and I’m sure the company trains their people well.”

Some staff told us that they did not always receive support following incidents. The registered manager did complete supervisions with staff, however staff told us that following incidents of concern there was not a formal process to ensure staff had the support they needed. We discussed this with the registered manager and provider, and they told us they would review this.

Most staff had completed training in infection prevention and control. Communal areas within the service were clean and maintained. Some people’s rooms were cluttered and had malodours and whilst staff told us they completed regular cleans within people’s rooms it did not seem this was always the case. The registered manager told us that people often refused support to clean their room, however they had successfully supported one person to reduce some items from their room. Other people’s rooms were clean and well maintained.

Medicines were not always managed safely. One person had paracetamol prescribed on an ‘as and when’ (PRN) basis. There was no guidance to inform staff when to administer the medicine, and the maximum dose the person could have in 24hours. This medicine had not been administered to the person. We reviewed medicine administration records (MAR) and identified days where MAR had not been signed by staff. This had not been identified by the registered manager. We observed a tablet on the floor of one person’s room, which had not been noted by staff, or identified that the person had not taken their medication. Once we highlighted this to the registered manager, they investigated and sought medical advice from healthcare professionals.