Abbey Ravenscroft Park Nursing 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 inspection we rated this key question requires improvement. The provider was previously in breach of the legal regulation in relation to good governance. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

At this inspection the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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.The ethos, values, attitudes and behaviours of leaders and care staff ensured people were treated with respect and dignity and staff treated people as equals. People told us they felt safe and comfortable and were able to live as ordinary a life as possible.

We noted considerable improvements in the home since our last inspection in May 2024. There had been some changes made by the provider and there was a new manager in place who had been in post for nearly 6 months. Although there had been a lack of strong management oversight of the home and consistent leadership we found a positive environment and an inclusive culture. The new manager had worked well to stabilise the home with the support of the provider and other senior staff.

Staff told us they felt included and could influence the way the service was run. All staff we spoke with told us they felt the service had improved in the past 12 months and they felt supported and empowered to keep people safe. A staff member said, “It is so much better and nicer. We all work together well and the manager is very supportive and approachable.” However, information we received shortly after our assessment informed us not all staff had positive experiences. We received assurances from the provider that they were working to ensure all staff felt included, involved and supported in the day to day running of the home.

There was an improved culture of effective leadership and teamwork to reinforce the provider’s vision and strategy. Staff and leaders communicated with each other in daily observations, staff meetings, and the availability and approachability of staff at all levels. A senior staff member said, “[Manager] has done a fantastic job in bringing everything together and improving our staff to make sure our residents get the best care.”A monthly newsletter was produced to highlight events in the home, celebrations of public holidays and the range of activities that people had taken part in. Newsletters were shared with people, relatives and other professionals.

We observed staff were respectful, caring and committed to providing good quality care and treatment to people living in the home. Staff were positive about the management team and complimented them for how supportive they were. The manager said, “It was very difficult at the start. We needed a culture change. There were language barriers but we had to give them opportunity to improve the way they communicate with residents. We have improved communication now and staff training. I think we are on track now. We needed more staff and we have recruited them.”

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 had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The home was managed by the home manager, a nominated individual who oversaw the management of the service on behalf of the provider and an operations director. Unit leads and senior staff also supported the management team. The provider had also employed a consultant to help develop more meaningful activities and strategies for interacting with people. The manager told us they were well supported and had daily discussions with provider representatives to ensure the service was compliant with CQC regulations. They said, “I am supported and can reach out to the wider team such as [head of operations]. We work together well.”

People and relatives spoke positively about the home and the management team. They felt the home was in a better place than it was previously. Relatives commented on the ‘nice, friendly, lovely staff’, the ‘cleanliness’ of the home and the ‘good care.’ A relative said, “Look, [family member] is happy here and that is the main thing.” Some people and relatives also made a point of praising the other staff in the home such as the receptionists, administrators and domestic staff. A relative said, “They are so wonderful and so on the ball. I even have written to the head office to let them know they are always checking things for me.” This showed that the provider had fostered an involving and positive culture where all staff, people and relatives were respectful of one another and acknowledged each other’s qualities and contributions in the running of the home.Staff were also positive about the management team and told us they were compassionate and cared for the staff and people they supported. A staff member said, “I can talk to the manager about anything. They are very kind, supportive and approachable.”

The service fostered a positive culture where people felt they could speak up and their voice would be heard. There was regular engagement with people and their representatives and a strong focus on supporting people to thrive, develop skills, have new experiences and live the life they choose. Staff said they were able to speak with the manager or unit leads (team leaders) to discuss any concerns. Staff felt they would be listened to and respected. A staff member said, “Yes, the managers always listen and give us opportunity to feedback and give our opinions.” People and relatives could contact the service at any time to speak with managers. A relative said, “Now I feel that I have someone to go to, the new manager.”

Records showed meetings took place with relatives, people and staff to listen to feedback and address issues as they arose. There were processes for staff to follow should they wish to speak with external agencies such as the local authority, the CQC or the police, if they were unable to report concerns about people’s safety to the provider or if concerns were not acted upon by the provider. The provider was open and transparent with people. They apologised to them and their relatives when things had gone wrong in the home or mistakes had been made.

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. Staff felt they were treated fairly by managers, and worked well with them as a team. Staff completed training in equality and diversity and had an understanding of what it meant. Recruitment and disciplinary processes were in place and ensured there was no disadvantage based on staff's specific protected equality characteristics. The provider had processes to ensure an inclusive workplace where staff were treated and supported as individuals. A staff member said, “The managers treat us very well. They are very good, very professional.”

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes and share this securely with others when appropriate. However, the service did not have a registered manager because of recent changes in the service. The manager and provider confirmed they had submitted their application to the CQC to ensure the service met legal requirements for a registered manager to be in place. We saw that their application was in progress at the time of our inspection.

At our last inspection, we found audits were not effectively identifying concerns. The provider had since made improvements. There were systems to monitor the quality of the service people received, which helped to identify if any improvements could be made. These included observations of staff competency, audits and team meetings. The management team worked with the operations director to complete quarterly and monthly care audits. Safety processes were also checked so they could be assured people remained safe. We saw that work was ongoing to continually improve the performance of the service.

The manager was visible and supportive, helping staff to perform and develop their roles. We saw throughout our inspection that they engaged with people and staff to check how they were and to listen to feedback. There were clear arrangements for accountability and a range of audits were completed across all departments to monitor quality and identify areas that could be improved. Monitoring systems were reviewed by the provider and actions were then taken to address any areas for improvement. Clinical audits ensured an oversight of these areas and ongoing clinical meetings and reviews ensured best practice was being followed. For example, pressure sores, wounds and other injuries were recorded, treatment was planned, monitored and reviewed using best practice guidelines.

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.

Leaders in the home worked well with people, families and professionals. They were able to network and contact external organisations, such as the local authority, for advice, guidance and developments within the health and social care sector. Professionals, such as GPs, nutritionists and training facilitators visited the home. The provider worked with national organisations such as Skills for Care and Learning Development Support Scheme to help develop their staff and follow best practice within the adult social care sector. Feedback from professionals about the service was positive. The local authority told us they were pleased with the progress the home had made since our last inspection in May 2024.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.Leaders worked with people, their representatives and staff to build a culture that focused on enabling people to enjoy a full life. The provider used technology to ensure people’s care records were up to date and accurate and the system was easy for staff to use.

Staff attended team meetings with the management team to discuss various matters. An internal action plan had been developed by the provider to help drive continuous improvements. Areas for continued improvement included care planning, safeguarding reports and making sure people had relevant capacity assessments in place, for example for their mental health needs or for bed rails. Meetings were held to discuss incidents and what lessons could be drawn from them. This showed that they had made progress and the provider was continuing to drive further improvements in the home to ensure all people received a service that was safe, responsive and effective.