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 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.

At our last assessment the service was in breach of legal regulation in relation to good governance. At this assessment we found the provider had failed to ensure necessary improvements were made and the service remained in breach of legal 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 understand the challenges and the needs of people and their communities. Care staff did not feel there was a culture of collaboration and joined up working. Staff described morale as low, stating they did not feel supported by the registered manager. There was a lack of shared direction and inclusion, preventing the service from focusing on improvement. Staff told us they did not feel concerns were listened to or acted upon.

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. The provider and the registered manager had failed to act on concerns raised at our last assessment and did not make all of the necessary improvements. For example, we found continued concerns and risk in relation to the use of medicines, infection prevention and control, care planning, and governance processes. Failure to act on these concerns and ensure quality of service, indicated the service was not being competently led, and meant people were not kept safe.

Staff told us they felt the service was not well-managed, and the registered manager did not support the team or understand the needs of the service. Some relatives we spoke with did not know who the registered manager was or told us they had very little contact with them. Staff and relatives told us they mostly engaged with the deputy manager, as they felt they were more visible and responsive.

Relatives told us they felt they could speak up and their voice would be heard. However, at times we found there was a lack of information regarding communication needs for people living with cognitive impairment such as dementia. This meant staff were not always given sufficient guidance to ensure people’s daily needs and wishes were fully understood. Staff did not always feel they could speak up and their voice would be heard. Some staff felt like concerns were not taken seriously or responded to appropriately by the registered manager. The provider’s policy supported freedom to speak up, however, a lack of oversight by the provider meant they had failed to act on related concerns raised at our last assessment. This meant that opportunities to utilise the views of staff to drive service improvement were missed.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. some staff spoke positively about workforce equality, however other staff indicated the culture at the service was not always fair and inclusive for all staff. Some staff raised specific concerns regarding conduct and interactions with the registered manager.

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 assurance processes were not effective. For example, medicine quality audits did not identify shortfalls, and environment and equipment audits did not support safe moving and handling practice. Most auditing processes were tick box processes that assessed compliance. They failed to evaluate systems to consider potential improvement. This resulted in missed opportunities to improve the quality-of-service people received.

There was a lack of oversight of recruitment processes, and we found paperwork to be very disorganised. In some instances, staff documentation was stored in multiple locations, was incomplete, and at times not dated. We also found there was a lack of oversight of staff competency assessments, and these documents were often stored in multiple locations. This meant that the provider and the registered manager could not be assured recruitment processes and competency assessments were completed in line with the provider’s policy.

There was a lack of oversight by the provider. This meant they failed to monitor the performance of the local management team at the service, to ensure necessary improvements were made, following the concerns raised at our last assessment in relation to the safe care and treatment of people and governance processes. This created additional risks to the safety and effectiveness of service provision.

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. 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. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. At our last assessment we raise concerns in relation to the safe care and treatment of people and governance systems. At this assessment we found the provider had failed to ensure required improvements were made and key learning points were identified. This meant that people were exposed to prolonged risk of potential harm and opportunities to embed and drive improvements in relation to governance were missed. There was a lack of oversight and monitoring of daily service activity to identify safety incidents and areas where the service people received could be improved. The provider’s governance systems were not effective at identifying shortfalls and driving improvement.