Ravenstone Care and Rehabilitation 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 remained the same.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 the legal regulation in relation to good governance.

This service scored 39 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a clear, shared direction and culture that promoted high‑quality, equitable, and person‑centred care. Systems and leadership arrangements were not sufficiently developed to ensure that the service’s vision, values, and stated purpose were understood, embedded, and translated into day‑to‑day practice.

The service supported a diverse group of people, including younger adults, older adults, people living with dementia, people with mental health needs, and people with a learning disability. However, there was limited evidence of a clear strategic approach to meeting this wide and diverse range of needs consistently and equitably. Shortfalls were identified in many areas, including the availability of appropriate equipment, meeting people’s social needs, and supporting people whose behaviours placed themselves or others at risk.

Whilst the home was called Ravenstone Care and Rehabilitation Home, there was a lack of evidence to demonstrate a shared understanding of the rehabilitation approach, or that goals were consistently planned, delivered, and reviewed.

Despite these shortfalls, relatives spoke positively about the culture of the service and the care provided. One relative told us, “It’s definitely very positive and the carers are happy. It is warm inviting an open and not hidden from me. Staff are kind to me and mum.”

Following the assessment, the registered manager told us they had received confirmation from the infection prevention and control team that people could be supported to prepare and cook food for themselves in the kitchen as a way of promoting independence. They also said they were exploring other ways to adapt the environment and provide staff support to further promote people’s independence, in line with people’s needs and risk assessments.

The findings of our assessment did not demonstrate that leaders were capable. During the assessment, we identified a range of shortfalls across the service, examples of which are detailed throughout this report. Leadership arrangements did not provide the oversight, direction, or support required to ensure care was safe, effective, compassionate, and person‑centred. There was no evidence of effective provider oversight, and records were not maintained to demonstrate how the provider monitored the quality and safety of the service, identified risks, or assured themselves that improvements were implemented and sustained. In addition, there were no records to demonstrate that the registered manager had received formal supervision or appraisal, which limited assurance that their practice and performance were being appropriately supported, reviewed, or developed.

Staff spoke positively about the registered manager and described them as approachable and supportive. Relatives also shared positive feedback, with one relative telling us, “The manager is good and approachable, and I see her most of the time. She is often in the kitchen helping.” During our assessment, we found the registered manager to be open, honest, and receptive to feedback, and they engaged constructively with the concerns identified during the assessment.

While a system was in place to support staff to raise concerns and speak up, this was not fully embedded in practice. Records showed that not all staff had completed whistleblowing training, which limited assurance that staff understood how to raise concerns safely or felt confident in doing so. In addition, staff meetings had not always been carried out as planned, which reduced opportunities for open discussion, shared learning, and reinforcement of speaking‑up arrangements.

Despite this, staff spoke positively about working at the home and told us they had no concerns about raising issues. One staff member told us, “I have no safeguarding concerns, and if anything ever arises, I am confident that such matters are always, recorded and reported to adult social care services.”

Following our assessment, the registered manager told us that training was being carried out. They also said that whistleblowing was discussed during staff supervision and that staff meetings were now being held regularly.

The provider promoted equality, diversity, and inclusion within the workforce. Staff told us they felt valued, respected, and treated fairly, and spoke positively about their experiences of working at the home. There was a diverse staff team, and people were supported by staff from a range of backgrounds who worked together respectfully. The provider held a sponsor licence, which enabled them to recruit staff from overseas where needed, to help support workforce stability.

An effective system was not in place to ensure clear governance and oversight. Shortfalls were identified across multiple areas, including risk management, medicines management, safeguarding, fire safety, environmental safety, staff deployment, the application of the Mental Capacity Act, record keeping and the monitoring of accidents and incidents. These concerns are detailed throughout this report. In addition, required safeguarding notifications had not been submitted to CQC prior to the assessment, which meant CQC did not have appropriate oversight of significant risks and incidents affecting people using the service.

There was no evidence of effective provider level oversight. Records were not maintained to demonstrate how the provider monitored the quality and safety of the service, reviewed performance, identified risks, or assured themselves that appropriate actions were taken and sustained. Audits and checks, where completed, were not consistently effective and did not result in clear action plans, timescales, or timely follow‑up.

Despite these shortfalls people and staff told us they considered the home was well managed. One staff member told us, “The home is well managed, the staff are experienced, caring, trained, and loyal. As the home is a small organisation, we know our residents very well, and they feel like an extension of our own families.” Relatives also spoke positively about how the home was managed, whilst recognising some of the challenges relating to the environment. One relative told us, “I think it is well run and it serves its purpose. It is old – the furniture and the décor, but they are doing a great job in a difficult situation.”

An effective system to support partnership working was not fully established. While there was evidence of engagement with external professionals, including the local authority, this partnership working was not consistently effective in driving improvements or addressing identified concerns.

The local authority had raised concerns on several occasions in relation to areas such as care planning, the assessment and management of risk, staffing levels, and staff training. These recurring themes aligned with the shortfalls identified during our assessment. This demonstrated that issues highlighted through partnership working had not been sufficiently addressed or embedded into practice, and that learning from external feedback was not consistently used to strengthen systems, improve staff practice, or enhance people’s experiences. Following our assessment, the local authority told us that the home was working with them to make improvements.

Despite the above shortfalls, we received positive feedback from a health and social care professional who told us, “The care home manager, has also been very responsive to any requests we have made.”

The service had not developed or embedded an effective culture of learning and improvement.

Although issues had been identified through incidents, audits, external feedback, and safeguarding concerns, there was limited evidence that the service consistently learned from these events or used them to drive sustained improvements in practice. Shortfalls were repeated across multiple areas, including care planning, risk management, medicines management, safeguarding, staff deployment, training, and environmental safety.

Systems to review incidents, accidents, and safeguarding concerns were not effective. Accidents and incidents were not routinely analysed for themes or trends, and learning was not clearly documented or shared with staff. Where audits were completed, including those relating to medicines management, fire safety, and maintenance, identified concerns were not always followed by action plans, timescales, or evidence of review to confirm improvements had been made and sustained.