The Red House Welfare & Housing Society

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

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 Requires Improvement. At this assessment the rating has changed to Inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulations in relation to governance at the service and the functions of the nominated individual.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

Staff described an underlying culture of bullying where concerns were raised about workplace behaviours, with some staff feeling that reports made to senior management and the registered provider were not always acted upon appropriately or taken seriously.

There was no strategic oversight plan for the service finances or future development to ensure the service was sustainable and support improvements in care.

People and relatives gave mixed feedback regarding staff culture. One person said about care staff, “Staff jovial jolly and we have a few laughs” but another told us how they were aware of a bullying culture amongst staff.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The registered manager left their role during our inspection. Prior to our inspection and the involvement of the local authority, the registered people had failed to demonstrate their capability to identify and address risks without delay. The concerns identified at this assessment as detailed throughout this report had not been identified or effectively managed until highlighted by inspectors and support from external professionals. The registered people including did not demonstrate they had the knowledge and experience to ensure regulatory requirements were met due to the significant shortfalls identified during this assessment. The registered provider had a board of trustees, but this also had failed to identify and action shortfalls.

When discussing a safeguard investigation, a senior leader from the registered provider used inappropriate language regarding the concerns. Their failure to understand the gravity of the event or show compassion evidenced a weak safeguarding culture.

During our assessment the provider was supported by the local authority safeguarding team. They also engaged an external consultant and interim manager who would be supporting them in the development of an action plan to drive change within the service.

People did not feel they could speak up and that their voice would be heard.

Prior to our inspection visits staff had written to the provider with concerns about the leadership within the service. The provider had failed to respond effectively to their concerns. Staff also gave us other examples of when they had raised concerns but had not been listened to. A member of care staff told us they had raised concerns about bullying but did not feel their concerns had been taken seriously and the problem continued.

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Due to poor oversight of the service leaders were not aware of the poor culture of the organisation in the context of equality, diversity, and inclusion. They were therefore unable to take appropriate action to address bullying and harassment concerns raised by staff. Disciplinary process had become extended and therefore ineffective.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider did not carry out any formal audits in the service to support effective governance and oversight. When asked about visibility in the service a member of the management team told us they visited once a week and took part in some craft work. The nominated individual is the senior person appointed by the provider organisation to be responsible for overseeing the management of the home and acting as the main link between the provider and the CQC. However, there were no formal or robust systems in place which demonstrated how they ensured oversight of governance, quality, safety, and compliance, the failures of which resulted in the concerns identified in this report.

When asked what audits they carried out, the registered manager confirmed they did not carry out any. We were provided with list of audits to be carried out in the service. For the majority, the section recording the person allocated to carry out the audit was blank. Others had been allocated to the deputy manager or a senior carer. They could not demonstrate any had taken place .

When the registered manager left their role, the registered provider did not provide effective oversight or alternative leadership. There was confusion amongst staff as to who was responsible for the day to day running of the service.

Following our inspection visits and with support from the local authority the provider appointed a consultant and an interim manager to address the failings and drive improvement.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Some care plans demonstrated consultation with external professionals such as the Dementia Intensive Support Team (DIST). However, other care plans recorded delayed referrals.

The provider 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.

A learning culture was not demonstrated by the service. The service could not demonstrate innovative practice. A lack of effective audits and analysis made learning from failings impossible.

While post-inspection feedback from the local authority highlighted positive progress, the provider's collaborative work with the consultant and interim manager was still developing. These necessary improvements represented a work in progress that required long-term commitment to ensure they became fully sustained and embedded into the culture of the service.