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 Inadequate. At this assessment the rating has changed to Require 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.

At our last assessment, the service was in breach of legal regulation in relation to governance at the service. At this assessment, not enough improvement had been made and the provider remained in breach of legal regulation.

This service scored 57 (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.

There was a positive rapport between staff and people living at the service. The atmosphere at the home was calm and relaxed. Staff worked at a relaxed pace ensuring people's immediate needs were well met. Staff spoke positively about leaders at the service and indicate a good staff morale. Staff described how they worked together as a team and supported one another.

The provider mostly had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation.

At the time of our assessment there was no registered manager in post. The provider had assigned additional personnel to support the service who were knowledgeable, competent and dedicated. However, lines of accountability, roles and responsibilities were not always clear, resulting in weaknesses in leadership, governance and oversight arrangements.

Staff told us that leaders at the service were approachable and available. Feedback from staff indicated improvements at the service had been made since our last assessment and the working atmosphere felt more relaxed.

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

People and staff told us they were able to raise concerns and felt these would be acted on. Not all staff were fully knowledgeable on pathways of whistleblowing, but understood how and when to raise concerns with leaders. Freedom to speak up was supported by the providers policies and procedures.

The provider valued diversity in their workforce. However, they did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Systems were in place to provide staff with supervisions and performance appraisals. However, these were not being utilised to their full potential by leaders. Leaders at the service described an informal culture around staff engagement and the reporting of concerns and other feedback, however this was not in line with the providers policy. Further development was required in this area to ensure staff received suitable supervision, support and performance development.

The provider did not 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.

Quality assurance and service oversight processes were not consistently effective at identifying shortfalls and did not fully manage risk at the service. For example, there was no process in place for auditing the quality of people’s care plans. In many instances there was a lack of sufficient detail within people's care plans to ensure staff had access to up-to-date guidance on how to meet people's daily needs. This exposed people to the potential risk of harm. There was no recorded oversight of people’s daily care records to ensure staff were meeting their needs safely, consistently and in a timely manner. This resulted in potential risks not being identified and addressed by leaders at the service. Area manager quality audits had not been completed in line with provider policy. This resulted in a lack of provider oversight of the service. A service improvement plan was in place, but this was not effective at ensuring service developments were completed in a timely manner. This resulted in people being exposed to prolonged risk of potential harm.

The provider was taking action to improve systems of governance at the service, but these had not been completed in a timely manner and shortfalls at the service remained. The provider had failed to fully respond to previous regulatory assessment outcomes and further improvements were still required.

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 engaged positively with other services to ensure people's needs were met. We observed staff working alongside community nurses to ensure people's medicine needs were met. Records indicated people’s health care needs were communicated with partner agencies. For example, one person was supported to attend a medicines review with their mental health practitioners when their needs changed as a result of declining health.

People were supported to engage and access their community when it was safe and appropriate to do so.

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 provider had not consistently sustained improvements. Although some concerns identified at the last assessment had been addressed, ongoing issues with care planning, quality assurance and leadership oversight showed that learning from previous concerns had not always been effective.

The provider had recently developed a new digital portal (Care Hub) to enable swift access to provider policies, new auditing processes and other essential information. Whilst this system had only recently been implemented, it demonstrated the provider’s intent for future development.