Archived: Rodney House 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 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 provider was previously in breach of the legal regulation in relation to good governance. Improvements were not found at this assessment, and the provider remained in breach of this regulation.

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.

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 fully understand the challenges and the needs of people and their communities. The provider’s website stated they specialised in residential care for mental health, addictions and complex behaviours. However, the provider failed to provide this model of care in an effective way and equip the staff team with the necessary skills, training and knowledge to deliver this. The provider had failed to ensure the correct CQC rating was displayed on their website. This meant any potential new people considering a move into Rodney House Care Home did not have a true and accurate reflection of the quality of the service provided. There was no documented evidence of regular discussions or meetings between the provider, the management team and staff to ensure a clear understanding of the specialised service the provider aimed to deliver. The absence of a clear, shared direction meant people received a poor standard of care based on their assessed needs and risks.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. There had not been a registered manager in post for a significant period. There had been a high turnover of managers in recent months which had created instability between the staff team and had significantly impacted on the quality of care provided. During the assessment the provider told us they had recognised improvements were needed and was in the process of bringing in a team of people to address the failings they were aware of, and which we identified. However, we found whilst there was a lot of activity to undertake reviews of aspects of the service, the purpose of some of the different roles was unclear. A lack of a cohesive overall improvement plan meant little progress was made to improve care.

People did not feel they could speak up and their voice would be heard. Some staff told us they would only raise issues anonymously for fear of reprisal or repercussion from the provider and members of the management team. Some staff told us they feared they would lose their job if they raised concerns and their identify was disclosed. Some staff did speak positively about some of the new managers employed, but not all. Feedback from staff was primarily focused on a perceived lack of support from leadership which had created low morale within the team.

The provider did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. The recruitment policies and procedures demonstrated a fair and equitable approach however, some staff didn’t feel they were treated fairly by some people who lived in Rodney House Care Home. Staff told us they faced racist and prejudiced comments on a frequent basis based upon the colour of their skin or their cultural background. Staff told us the management team was sympathetic to listen to them when they raised concerns, and would speak with people, but didn’t feel any real action was taken to address the behaviour with people. This change does not affect the score and or rating for this domain.

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. There was a lack of clear auditing undertaken at Rodney House Care Home. This meant many of the failings we identified were not known to the provider, or the management team. Significant cleanliness, health and safety and environmental concerns were not picked up through any form of routine audits. This resulted in people living in an extremely poor and unhygienic environment. Many risk assessments and care plans were missing, out of date or lacked sufficient detail about people’s needs. When people needed specific health monitoring to reduce the risk of ill health, this was not being recorded. Handover records did not reflect the current people in receipt of care, nor did it accurately reflect their most important care needs. There were no effective systems for the management team to maintain oversight of people which had placed people at serious risk of harm. The provider did not use the assessed risks of people to identify and ensure staff received essential training to keep people safe from harm.

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. Whilst staff worked in partnership with other health and social care partner agencies, they did not work closely with community and leisure groups. This left some people isolated from taking an active part in their local community.

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. There had been a significant lack of oversight of events which occurred at Rodney House Care Home. There had been no recent analysis to learn from accidents and incidents or identify opportunities for improvement. Quality assurance systems were either not in place, poorly completed or ineffective, which limited the providers ability to drive improvements which enhanced quality of life for people using the service. There was no formal system in place to gather or share feedback from people, family members, or staff, and there was no evidence of learning being shared through meetings. The management team had held several team meetings in recent weeks, however, little or only very brief notes of discussions were recorded. This meant staff who were unable to attend could not keep up to date with information shared.