Ridgegate Home

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• 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 Requires Improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance, particularly in relation to a lack of robust auditing and poor record keeping for people.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Although management had a shared vision and culture based on transparency and equity, this did not always reflect in the way people’s care was being provided to them.

The registered manager told us, “I think we are nearly there (on the care side). We are one big family and the residents say they feel part of the family.” However, we did receive some mixed views during our visit, where people told us they felt they were not always provided with information and activities were not meaningful to them. In addition, there were inconsistent experiences for some people as we have reflected in our Responsive key question.

However, generally people received a good level of care and overall, the feedback we received was positive. One person told us, “The manager is alright” and a relative said, “We are so grateful to all at Ridgegate for the way they look after the people in their care.”

Staff felt there was good teamwork amongst them and that they all had a shared wish to provide good care. We were told, “We are quite happy working here, but more activities could be introduced” and “We have domestic and kitchen, care and the senior care and activities. It’s separate but it’s not. [Registered manager] is a support, she is always there for anything.”

Not all leaders had the skills, knowledge, experience to lead effectively.

The registered manager told us they felt supported in their role by senior management and the provider supported them if they need to purchase new equipment for the service, for example, or make changes. However, although the registered manager was an experienced member of staff, they lacked some knowledge in relation to the requirements of registration as well as the Regulations. For example, notifications of suspected abuse had not always been raised with CQC as per the requirements of registration and although we discussed the Single Assessment Framework quality statements with them, it was evident they were unclear on how to evidence they were meeting them.

The provider told us following our inspection that whilst the registered manager had shown commitment to them and the service, they recognised the pace of improvement they felt was needed had not been ‘adequate enough’. As such, they had recruited an external consultant to support the registered manager once per week and had taken the decision to recruit a permanent home manager.

Management fostered a positive culture where people felt they could speak up and their voice would be heard.

We received positive feedback from relatives in relation to being able to raise concerns or complaints. We were told, “The manager was very helpful and I would feel comfortable raising things” and “It’s like a family here.”

The registered manager told us, “My door is always open. We all talk and get on. The care staff are getting tighter now. It’s been a difficult year (due to the safeguarding issue) but I am hoping we can get back to the old Ridgegate and how things used to be.”

Management valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The registered manager told us they had improved their processes to ensure there was equity within the workforce and to enable this the interviews during the recruitment period had been changed and strengthened. They said, “Since the safeguarding concern where we had staff working here who were related, we have changed our HR processes and are more robust now with extra checks. We still have staff across all cultures, and we also have a sponsored staff member here. There were a lot of agency staff, but we have recruited more and we are working more as a team."

Management did not have clear responsibilities, roles, systems of accountability and good governance.

Several audits took part in the service to measure the quality and safety of the care provided to people. However, these audits were not robust and as such shortfalls were not being identified. We read in the care plan audits as well as the medicines audits that the registered manager had written ‘all standards met’. Yet, we had found poor records relating to people’s care plans and poor medicine management practices. We also found items in the first aid box which were out of date, despite this being checked regularly. In addition, a recent pressure prevention audit also stated ‘all standards’ met but we had found 1 person’s pressure relieving equipment was not set at the correct level meaning the effectiveness of the mattress could be compromised.

The provider completed an audit and although they had identified some actions, these had not been completed by the registered manager. For example, it was identified accident and incident records were not completed or detailed. The deadline for reviewing and updating these was July 2025 and yet this work had not been carried out and we found similar concerns on our review of the records. In addition, some of the areas checked by the provider were shown as requiring no action, such as medicines management, safeguarding notifications and people’s care plans. This was despite us picking up shortfalls in all of these areas.

The registered manager understood their duty to collaborate and work in partnership with external providers and the local community.

There was evidence of collaboration between staff and healthcare professionals, such as the GP, district nursing team, physiotherapist, mental health team, dieticians and the chiropodist. This helped ensure people received the most appropriate input in their care and treatment.

In addition, the registered manager said they had good links with the local church who held services in Ridgegate Home every other week and a local school who was commissioned to do a painting of the home.

The provider did not always focus on continuous learning, innovation and improvement across the organisation as governance arrangements were not highlighting what needed to improve or change within the service, such as the care plans and medicines practices, and learning was not being taking from accidents and incidents.

But general improvements were being made to help with the paperwork and administration as the service was moving to an electronic care planning system as well as a new human resources system. Management told us this will help them focus on ensuring care plans were more person-centred and gaps were identified and rectified. In addition, recruitment checks and documentation relating to those will be held electronically.

In addition, we were told plans were in place to improve people’s experiences in relation to activities and social engagement. This included the art teacher from a local school coming in weekly to lead art sessions, the registered manager looking at opening up the service to regular coffee morning for locals and following a recent financial donation the introduction of more varied activities.