Redcote House Residential 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 remained 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 the governance at the service.

This service scored 50 (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 and strategy that was shared with staff. The registered manager explained their personal values for example, to ensure staff worked together to achieve good outcomes for people. However, these were not shared with staff, and we found they had not always been achieved. There was not a culture of continuous learning to improve people’s quality of life. Debriefs were not carried out following incidents to identify lessons learned and improve future practice to achieve better outcomes for people.

Not all leaders understood the context in which the provider delivered care, treatment and support. Although staff felt they could approach managers with concerns and they would be addressed, managers were not always proactive in identifying poor practices that could impact the quality of people’s care and well-being. The registered manager had not always kept themselves up to date with their professional knowledge to ensure they were providing the best possible care and meeting the regulatory requirements. However, the registered manager was open, honest and transparent during the inspection. Where shortfalls were identified during the inspection, the registered manager was responsive and showed a commitment in making required improvements.

People and their relatives felt they could speak up and their voice would be heard. However, some relatives told us they did not always think appropriate actions were taken or concerns were fully responded to. Staff understood how to raise concerns if they felt the management team had not satisfactorily responded to them or people. However, the lack of effective quality monitoring in place meant there was no overall service improvement plan to improve care quality across the service.

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 the online system allowed them to put notes on days where they would prefer not to work and the registered manager acknowledged these to support a more flexible work life balance. Staff who had worked in the service for a while, told us conditions were improving daily and the registered manager always checked on their wellbeing to ensure they were ok.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Managers did not ensure governance systems were effective, and appropriate actions were taken to improve the safety and quality of the service.

The registered manager did not always notify the CQC when required which is a process to ensure transparency and accountability. For example, notifications were not made when people had assaulted other people who used the service and notifications for serious injuries were not reported in a timely way.

Managers did not assess whether incident forms were completed following incidents and that actions taken to mitigate risks were appropriate, proportionate and justified. The lack of incident records meant the registered manager was unable to analyse incidents to identify patterns which led to ineffective strategies to try and improve people’s quality of life. There was inconsistency in practice when medicines were used for people experiencing distress. The provider relied upon staff judgement instead of regularly reviewing and monitoring the use of restrictive practices.

Further work was needed to ensure there was a system of management oversight to ensure essential tasks were being carried out, such as when repositioning was required to prevent the risk of pressure wounds. This increased the risk that people’s needs would not be met. We could not be assured people’s individual care plans, risk assessments and monitoring care records were regularly reviewed and reflected people’s current care and treatment needs.

Actions were not taken such as regular monitoring of a person's weight when they were frequently declining to eat or eating small amounts of their meals which meant interventions had not been taken to reduce the risks to their health.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. The provider did not engage with partners to share learning to support continuous improvements to the service. Feedback from some professionals was critical of the registered manager’s engagement in initiatives to help improve staff skills and knowledge. People were not supported to engage with their local community or be part of local organisations or support networks to promote good physical and mental health.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. Incidents had not been analysed by the management team to look for themes and patterns. Actions taken by the service lacked analysis so these could not be shared in team meetings with staff for them to embed learning and improve care outcomes for people. Staff meetings showed some incidents were discussed, however, when people were regularly distressed, there was no structured opportunity to help teams cope with the emotional impact of incidents, enhance communication, and promote a culture of safety and learning.