Safeguarding Adults Board review of Western Rise Care Home

Published: 7 October 2016

Today, 7 October 2016, the Torbay Adult Safeguarding Board has published its review of the Western Rise Care Home with 25 residents. The review was called for following a safeguarding adult concern being raised to Torbay Safeguarding Adults Team in June 2014.

The concern led to an intensive multi-agency safeguarding whole service response and regulatory action by the Care Quality Commission. The review focused on why the poor standards of care were not identified as a concern prior to June 2014 despite regular visits to the home by health and social care professionals. The review was commissioned under the Torbay Safeguarding Adults Board Serious Case Review (SCR) procedures, and was undertaken by an independent reviewer.

The review considered a number of issues that had occurred and how professionals visiting the home did have care quality concerns but this information was not communicated across agencies and no overall picture was seen. The review makes a number of recommendations aimed at improving communication and training in order to ensure there are consistent and clear objective standards of what constitutes good care; how to identify at an early point when agencies should intervene and what should be done to prevent any delay in concerns being raised and looked into.

Throughout the review period learning and recommendations have been shared and we know that many have already been implemented. Since the original events there have been changes in national policy and practice that are relevant to the themes identified and systems and standards have been addressed. Local policy and practice has also, in many cases, already been reviewed and revised.

Julie Foster Chair, Torbay Safeguarding Adults Board said:

“I believe this has been a very thorough review and from it a number of lessons have been and will be learnt. What we have seen is that many of the professionals who visited the home saw things that they believed were not good but they believed had to be accepted for vulnerable people for whom there were few alternatives. There was no collecting and sharing of these observations and therefore no overall picture was seen. Visiting professionals thought that the care home staff were doing a reasonable job, in demanding circumstances.

“I am struck by the lack of shared understanding of what constitutes inadequate care and key recommendations in this report are that partners work more closely together to share intelligence, improve training and ensure that each resident has a personalised care plan that is made available to all professionals.

“Lessons have been learnt by all the organisations involved, both through this SCR process, but also more immediately from their own responses after the events at Western Rise.”

Throughout the review the Torbay Safeguarding Adults Board have ensured that individuals and families have been kept informed of the progress and all have had the opportunity to discuss this review prior to its publication. Western Rise Care Home that was based in Torquay closed earlier in 2016.

For more information, on behalf of the Torbay Adults Safeguarding Board contact Jacqui Gratton, Torbay and South Devon NHS Foundation Trust, 01803 217398, email Jacqui Gratton.


The Torbay Safeguarding Adults Board (TSAB) leads adult safeguarding arrangements across our locality and we oversee and coordinate the effectiveness of the safeguarding work of our member and partner agencies.

The TSAB believes that:

“Every person has a right to live a life free from abuse and neglect. It is ‘Everyone’s Business’ to ensure that we work together as a community to support and safeguard the most vulnerable in society”.