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 inadequate. At this assessment the rating has changed to requires improvement.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The provider was previously in breach of the legal regulation in relation to good governance. Not enough improvements were not found at this assessment, and the provider remained in breach of this 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.

People, relatives and staff all felt the recent improvement changes had been noticeable and had enhanced Radcliffe Manor House.

Staff meetings took place and gave staff an opportunity to share ideas and suggestions. Staff told us they were more informed when changes took place and communication from leaders had improved.

There were relative and resident's meetings and letters had been shared with relatives about changes taking place, ensuring that all were informed. This included changes following the last CQC assessment, as well as planned changes to improve the building, such as changing flooring.

There was a service improvement plan in place to track developments and ensure the required measures were taken to maintain the service to a high quality, safe standard. However, issues highlighted from audits and lessons learnt had not been embedded within the service to ensure that changes were effectively implemented. This meant that good governance required further work to ensure that the service implemented changes successfully.

The provider 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. Leaders led with integrity, openness and honesty.

Feedback we received from staff was mixed about the changes that had recently been implemented and actions taken by the management team. Staff we spoke with told us the management team were very approachable and supported them to carry out their role. One staff member told us, “From the start I felt welcomed and well supported.” However, other staff felt that leaders lacked presence around the home. The lack visibility of leaders was also raised by some people who live at Radcliffe Manor, who told us they did not know who the management team were. This meant that people would not know who to approach if they required support from the management team.

The nominated individual had a service improvement plan in place, with regular auditing being completed by the management team to assess progress. However, we saw some of the areas of concern on the service improvement plan had not been reviewed for some months and lacked detail around when it would be reviewed and effectiveness of the changes had not been measured. For example, it was documented that peoples care plans did not reflect peoples identified needs. This service improvement plan did not show a review of this for 3 months. This left people exposed to the risk of harm in the immediacy.

The provider fostered a culture where people felt they could speak up and their voice would be heard. Staff felt able to raise concerns and give feedback and feel they had been listened to. Staff told us they felt confident in speaking up if needed. One staff member told us, “I am able to share my views and feel that they are listened to and replied back to in a timely manner.”

Staff told us they felt able to speak up and were aware of the Whistleblowing policy.

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. Policies and procedures were in place to ensure equality in the workplace. Staff felt supported by the management team and told us they were approachable.

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

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. Concerns were not always promptly identified and addressed.

Care plans and mental capacity assessments had not been completed thoroughly which meant that when staff unfamiliar with the service worked with people, they would not have the most up to date information on how to care for them. When this was fed back to the provider following the onsite assessment, action was taken and evidence provided of care plans that had been reviewed and were reflective of peoples current needs and wishes.

The service improvement plan held by the provider highlighted concerns around auditing and how lessons learnt had not always been embedded within the service. This meant that lessons learnt from incidents within the home had not always been carried out to mitigate future risks. This was discussed with the provider who was aware of this and discussed plans on how they would prioritise ensuring lessons learnt are shared within the service in order to manage risk and areas for development.

Action was taken following our assessment, but systems and processes required further updating and embedding into practice to ensure they were effective.

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 told us how they worked in partnership with other professionals to ensure people were included in their communities and had access to relevant services. For example, when people had not been drinking enough fluids, the management team escalated the concerns to the relevant external health care professionals for support and guidance.

The provider focused on learning, innovation and improvement across the organisation, however further work is required with embedding systems into place regarding lessons learnt. They actively contributed to safe, effective practice.

Staff told us they felt listened to, valued and able to speak up and voice their ideas and suggestions. However, systems in place to learn from incidents required strengthening, to ensure staff and leaders learnt how to improve the service and mitigate future risks. The provider’s service improvement plan had highlighted this as an issue. Incidents were being reviewed and added to the governance document, but lessons learnt were not always robust or into staff meetings.

We found complaints did not always show a response or a reflection for lessons learnt. However, people we spoke with told us they were happy with the responses they received from the provider with any concerns they raised.

Where concerns were identified during the inspection, the provider was open in acknowledging shortfalls and were prompt to evidence what steps they were taking to review and amend their processes to drive improvements in the service.