The Old Rectory Care Home

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 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 governance.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The registered manager and staff team promoted a culture at the service which was focused on providing good care and outcomes for people through good communication and valuing person-centred care

Staff told us about their values which included, “If you work in care you have got to care. Every day we remember we work in the resident’s home. The way we care is first above everything else. If the residents are happy, we know we are doing things right.” and “The manager and all the staff come to work to give the best care to the residents in their home. That’s an approach we all share, and you need to share to work here.” This was consistent with the service’s values, which the registered manager confirmed focus on providing the best possible care.

The provider had compassionate and inclusive leaders, however, they did not always have the skills, knowledge and experience required to ensure robust systems and processes were in place to provide effective oversight of the service.

For example, during our inspection, we identified that some medicines were stored incorrectly because the registered manager was unaware of the correct storage procedures.

Staff feedback suggested that greater visibility and engagement from the provider was needed. Comments included, “I have never seen the owner in all the time I have worked here.” and “I saw the owner once, but I don’t think they even spoke to me.”

However, staff working at the home spoke positively about the registered manager. One staff member told us, “Our manager in a word, ‘fantastic.”

The registered manager told us they felt supported in their role by the provider, telling us, “I can pick up the phone to the provider any time.”

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

Staff felt confident to raise any issues or concerns with the registered manager if needed and were confident action would be taken. One staff member told us, “I would never worry about speaking out. In fact, we are encouraged to be open and honest.”

The registered manager told us, “Staff know they can come to me with any concerns, and I will deal with it.”

Staff told us they had regular team meetings. However, these were not documented.

Information about policies to support a culture of speaking up such as whistleblowing and complaints were available within the home.

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

Staff told us they felt included in decisions about the service and spoke positively of the registered manager. One staff member told us “The manager is encouraging me to do my qualifications. I wasn’t sure, but [registered manager] tells me I would do really well which is nice.” Another staff member shared how other staff and the registered manager had been supportive by covering and rearranging shifts when needed. They told us, “The manager is accommodating. They will change shifts around to support life outside of work.”

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.

Quality monitoring systems needed improvement and were not always used appropriately. We noted that some recorded checks did not align with what we observed. Checks failed to identify significant issues, including damaged equipment, gaps in toilet cleaning charts, and rooms documented as deep cleaned but found dirty. Daily walk-around checks were not recorded, limiting the ability to identify and address environmental concerns, which could lead to increased safety risks to people. Audits were not always effective. Monthly medicines audits had been completed but did not cover all aspects of medicines management. For example, auditing did not include checking medicines were being stored correctly. Audits had not identified the concerns we found. The registered manager accepted our feedback and said they would review the audit tool in use.

The registered manager deliberately left the deputy manager role vacant to provide senior carers with development opportunities. However, this decision created a gap in the management structure and placed additional pressure on the registered manager, who then took on all operational and compliance responsibilities. As a result, the effectiveness of quality monitoring was reduced, as there was limited capacity for this.

Care records were stored in a cupboard in a communal area. During our first visit, we found this cupboard to be unlocked. We found the cupboard remained locked throughout the second day of our inspection.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff recognised the importance of maintaining close connections with external health professionals to ensure people received the right care for their health and wellbeing. One staff member told us, “The nurses visit, and we know who they are, the same as we know the doctor. Being a small home makes it more personal and easier to get to know everyone and work together.”

The manager had established community links and had plans for a local school choir to visit the home. Children from a nearby nursery also attend during Easter to observe chicks hatching, promoting positive engagement and encouraging connections across different age groups.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The service did not hold regular resident and family meetings or distribute formal feedback surveys. These approaches can provide a more accurate understanding of people’s views and highlight areas for improvement within the service.

The registered manager was committed to delivering good care and recognised that further systems needed to be implemented to improve on and record safety and quality checks.