Rock House

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

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 there were widespread and significant shortfalls in service leadership. The provider was in breach of legal regulations in relation to the governance of the service and notifying CQC of incidents. Leaders and the culture they created did not assure the delivery of high-quality care. Checks and audits had not always been completed, and when they had they had not identified the serious and widespread issues highlighted within this assessment. There was a closed culture within the service, which did not always support positive outcomes for people.

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.

Staff at all levels did not always prioritise safe, high-quality, compassionate care. Language used by staff at all levels to refer to explain people and their needs was not always respectful. For example, one leader told us they were concerned that if they did not have their alcohol policy enforced it could lead to ‘drinking dens’ within communal areas. One staff member referred to people by their room numbers which is not respectful. There was a closed culture at the service which leaders had not identified or acted on. A closed culture is a poor culture that can lead to harm and people’s human rights breaches such as abuse. For example, the staff office door had a sign that stated people ‘must knock’ before entering and ‘must not enter’ if staff did not respond.

Leaders were not alert to examples of poor culture that affected the quality of people’s care and had a detrimental impact on staff. Despite this infringing on people’s human rights, leaders had not identified the restrictive practices within the service, for example locking bathroom doors and the use of CCTV to monitor people during distress without their consent. The principles of RSRCRC were not embedded throughout the service despite supporting autistic people.

Leaders were not always knowledgeable about issues and priorities for the quality of services and could not always access appropriate support and development in their role. The registered manager had not engaged with local forums networks to learn and improve the service and share good practice.

There was not always a culture of speaking up where staff were empowered to raise concerns outside of the organisation. Staff we spoke with did not know who they could raise concerns with (for example the local authority safeguarding team). Staff did not always feel that they could speak up and that their voice would be heard. For example, one member of staff told us they did not receive support following incidents. They told us they just accepted this practice.

Leaders did not always take action to continually review and improve the culture of the organisation in the context of equality, diversity and inclusion. Leaders did not carry out audits on the culture of the service. Leaders did not always ensure there were effective and proactive ways to engage with and involve staff, with a focus on hearing the voices of staff with protected equality characteristics and those who were excluded or marginalised, or who may be least heard within their service. Staff told us that leaders did not always make reasonable adjustments when they returned from work following a period of sickness.

Systems to review and improve the quality of the service were not effective. Checks and audits completed by staff and the registered manager had failed to identify and address the significant issues identified within this assessment. There had been no compliance audits completed by the provider since 2023 due to another of the providers locations needing support. The provider failed to identify that significant risks including to people’s health and wellbeing had not been identified and mitigated.

Services that provide health and social care to people are required to inform the Care Quality Commission, (CQC), of important events that happen in the service. This enables us to check that appropriate action had been taken. The registered manager had not always submitted statutory notifications to CQC as required.

Whilst staff and leaders worked in partnership with the mental health services to promote joined up care, this was not always reflective with other services such as the dentist. Leaders did not engage with people, communities and partners to share learning with each other that resulted in continuous improvements to the service. Leaders did not use these networks to identify new or innovative ideas that could lead to better outcomes for people. The registered manager did not engage with local forums or networks including the registered managers forum.

Leaders and staff 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. Processes to ensure that learning happened when things went wrong, and from examples of good practice were poor. We found that significant incidents re-occurred without learning, reviewing of care plans or sufficient mitigation implemented by leaders. Leaders did not encourage reflection and collective problem-solving. There was not a formal process to allow staff to de-brief.