Radcliffe Manor House

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.

The service was in breach of legal regulation in relation to governance at the service.

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. Staff gave varied feedback on the management team. Some staff explained that the managers were supportive and approachable. Other staff felt that the management team did not have good lines of communication.

There was not an open and honest culture. Systems were not used effectively to ensure people, their relatives and staff were listened to. The feedback we received told us that actions were not followed up and feedback from meetings was not shared.

Leaders did not create a shared culture of effective care, meaning there was a poor-quality culture at the service. This is because low staffing levels meant that people’s preferences, and dignity was not always supported.

Whilst the provider had systems and processes in place to foster an open and honest culture, these were not utilised by the management team at Radcliffe Manor House. More work was needed to ensure that there was appropriate and consistent oversight in place at all times as referred to in other areas of this report.

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 had systems and checks in place, but we found these were not completed accurately by the local management team which meant the provider’s oversight and view of the service was inaccurate.

Leadership had recently changed at Radcliffe Manor House, however at the time of the assessment, staff were not confident in the leadership at the home and felt they did not have much of a presence with those who lived there.

Most people we spoke with were either unaware of who the current manager was or rarely saw them. One relative told us, “I don’t see them around really. It’s difficult to talk to anyone and get answers.”

People did not always feel they could speak up and that their voice would be heard.

Staff told us they felt able to speak up and were aware of the Whistleblowing policy, however they were not confident that action would be taken on issues that they may raise.

The provider told us that they had communicated the recent change in management to people who use the service and their relative through relatives meetings as well as writing to them. However, when we spoke to people and relatives, they were unaware who the manager was or explained that they do not regularly see them around the service. They also explained that there were some meetings for relatives and people to attend, however they felt these were not very regular. They felt they did not always receive feedback about actions taken after the meeting. Therefore, we were not assured that there were effective processes in place to allow people to speak up.

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.

Radcliffe Manor House employ a diverse workforce. Some staff felt that they were treated equally, other staff felt that the management team had favourites within the staff team. Whilst policies were in place, leaders did not use effective ways to evaluate how staff felt or were aware of the poor quality of care provision. Individual supervisions were not frequent to enable open discussions between staff and management.

Staff had completed training in equality and diversity and understood the importance of respecting differences and ensuring an inclusive workplace.

The provider did not have clear responsibilities, roles, systems of accountability and good governance.

At the time of our assessment, the registered manager had recently left the service. A new manager was in post, however at the time was not the registered manager for the service with CQC. The leadership team told us at the time of the assessment that they relied on the support and guidance of a consultancy firm. Additional training for the new manager had not been provided at the time of the assessment in order to support them in this role. We raised this with the provider who told us that this would be arranged.

Although all of the staff we spoke with told us the provider management team were in the building, they did not have a presence outside of their office. The systems and processes to monitor quality and safety were not effective in protecting people from the potential risk of harm. The provider had not identified all the shortfalls in the expected care standards found during this assessment. For example, audits had not identified that wardrobes were not secured to walls, balustrade heights were not risk assessed and radiator pipes were exposed. None of these issues had been addressed prior to our assessment. We did raise these environmental concerns with the provider who was reactive to our findings, taking immediate action to make the environment safer.

Care plans did not accurately reflect people’s current needs. Risks known to staff had not been documented and mitigated. Records in relation to people’s mental capacity and associated Deprivation of Liberty Safeguards (DoLS) applications were not effectively reviewed with relevant referrals not being made. This meant that people were being unlawfully restricted.

Staff were safely recruited with the relevant checks in place.

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 and their relatives told us they were not involved in reviewing their care needs. Some people could not recall ever having discussed their care, whilst some recalled only being involved in these discussions when they first moved to Radcliffe Manor House.

There was no evidence seen in relation to communication with people, staff or partners for sharing ideas and learning. Issues were seen to have been shared in governance meetings but changes and actions from these were not widely shared and implemented meaning that learning could not be embedded.

We asked the provider to supply an action plan on urgent concerns found during the assessment, for which they were responsive with actions they would be taking.

We received mixed feedback from external bodies, however the local authority provided good feedback in their most recent quality assurance report completed earlier this year.

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. They did not actively contribute to safe, effective practice and research.

The provider had systems and process in place to share lessons learnt but these were not utilised or effective at Radcliffe Manor House. Analysis of accidents or incidents to ensure lessons were learnt were not effectively conducted. Whilst there was a lessons learnt standing agenda item at staff meetings, minutes we reviewed detailed incidents and complaints were simply discussed and no discussion of what learning took place. For example, one meeting discussed how there had been 2 complaints and they had been dealt with. No details of actions and lessons learnt were documented as being discussed.