Richard 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 good. At this assessment the rating has changed to 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 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.

A shared direction and positive culture were not consistently embedded. While some staff demonstrated commitment to compassionate care, this was not supported by a clearly shared vision, values or strategy that were consistently understood or applied in practice. Frequent leadership changes, limited management visibility and inconsistent follow‑through on concerns reduced confidence and trust among staff and relatives. People, relatives and staff did not always feel listened to or involved in shaping the service. Arrangements to promote equality, learning and improvement were not fully effective. As a result, there was reduced assurance that the service had a cohesive and inclusive culture that consistently supported safe, person‑centred care and continuous improvement.

Following feedback, the provider had begun actively engaging with people and their relatives to seek their views and improve understanding of their experiences.

Leadership arrangements lacked clarity and continuity, and people and staff were not always clear about who was in charge on a day‑to‑day basis. Although managers were present in the service, leadership responsibility was not always clear or well‑coordinated. This affected how concerns were escalated and addressed, and meant staff did not consistently feel guided or supported. As a result, confidence was reduced in leaders’ ability to provide clear direction, respond effectively to concerns and maintain oversight of the service.

Following feedback, the provider took steps to strengthen leadership arrangements and oversight. Management and senior staff training was arranged to improve leadership skills, role clarity and accountability. Management presence within the service was increased to provide clearer guidance and support to staff. The provider also introduced clearer learning from incidents processes and revised audit arrangements to improve escalation and oversight.

Arrangements to support staff to speak up were not consistently effective. Staff did not always feel confident that concerns would be listened to or acted on. Some staff said they had raised concerns but felt these were not acted upon, which reduced trust in escalation and whistleblowing processes.

Leadership arrangements did not provide enough assurance that staff were encouraged or supported to speak up, or that learning would result from concerns raised. As a result, there was less confidence that staff felt safe to raise concerns openly in order to protect people using the service.

Leadership and governance arrangements did not consistently enable staff to carry out their roles effectively. Staff described ongoing staffing pressures and high workloads, with limited flexibility or support across roles and shifts. Arrangements for supervision, training and development were not consistently effective in supporting staff to feel enabled in their roles, which affected the service’s ability to maintain stability and consistency.

Following feedback, the provider started to take steps to improve staff wellbeing and support arrangements. These actions were at an early stage and had not yet resulted in sustained improvement at the time of inspection.

Governance arrangements were ineffective and did not ensure safe, consistent or high‑quality care. Although the provider had systems in place to monitor quality, risk and performance, these were not used effectively to identify concerns early, understand risks or take timely action. Audits and oversight processes did not consistently result in learning or improvement, and accountability for actions was not clear.

Information relating to incidents, falls, medicines and care quality was recorded but not regularly analysed or reviewed in a way that led to service improvement. Issues were evident over time, indicating that governance systems were not effective in learning from experience or reducing risk. As a result, leaders did not have a clear and accurate understanding of risks within the service, and governance arrangements did not support sustained improvement in quality and safety.

After feedback, the provider took steps to improve how the service was run. They changed audit processes, so issues were looked at more closely, introduced a clearer way of learning from incidents, reviewed care plans to make sure risks were identified and increased staffing. These actions were taken after the inspection, showing that governance systems had not been working effectively beforehand.

Partnership working was not consistently effective. While staff made some attempts to work with external services and agencies, collaboration was not always well coordinated or proactive. Information was not consistently shared in a way that supported joined up care or timely outcomes for people. There was limited evidence that learning from partners or the wider community was routinely used to improve the service. As a result, there was reduced assurance that partnership arrangements were strong enough to consistently support seamless care, positive outcomes or sustained improvement for people using the service.

Learning, improvement and innovation were not embedded in day‑to‑day practice. Systems were in place to record audits, incidents and concerns, but these did not always highlight problems clearly or lead to timely review. When things went wrong, issues were not consistently investigated in enough detail and action was not always taken to prevent them happening again.

Lessons were not routinely shared or used to improve practice. People, relatives and staff were not always involved in identifying what needed to improve. As a result, there was less confidence that the service was learning from experience or using its systems to improve safety and quality of care.

Following feedback, the provider planned to strengthen audit arrangements to better support learning and improvement. This included requiring audits, such as call bell analysis, to capture peoples’ experiences, with clear records of who had been spoken to and their views and lived experiences.