Restgarth 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. This is the first assessment for this newly registered service. This key question has been rated 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 management of the service.

This service scored 32 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Due to the inconsistent oversight there was not a clear vision or culture within the service. Staff told us they were ‘constantly firefighting.’ There were limited opportunities for managers to share organisational values with staff. Staff had not had supervision sessions where they could discuss any issues or gaps in training. Staff meetings had been held in response to safeguarding concerns, but these had been infrequent.

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.

There was no manager at the service. Managers from 2 of the organisation's sister homes had been providing support but this was largely remotely. One manager visited the service monthly. A deputy manager was employed. However, records showed they were sometimes required to cover staffing gaps, providing care or working in the kitchen, and did not always have the time to complete managerial tasks such as updating care plans.

Professionals told us staff lacked guidance, and staff told us morale was low. There had been a high turnover of staff, and one manager told us some new staff had left very quickly after starting work. They were trying to address this by improving systems for support during induction. However, we saw one new member of staff was working without completing any shadowing shifts. This meant they had not had an opportunity to build their confidence and observe more experienced staff.

Following the inspection the provider recruited an interim manager to oversee the service and work to make the necessary improvements. They were also actively looking to recruit a new registered manager.

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

Staff told us morale was low in the team, and one told us they were ‘at breaking point.’ Staff told us they had spoken with leaders about people’s needs not being met but did not feel this was acted on. Comments included, “[Name] doesn’t seem to understand how bad things are” and “We are told things will improve, lots of promises, but it doesn’t change.”

The provider had not ensured an inclusive and fair culture by improving equality and equity for people who worked for them.

Some staff told us they did not feel valued. One member of staff described how they had stayed on to support the service when they were short staffed. They commented, “I’ve got more responsibilities than before."

However, other staff told us they were well supported. Staff from overseas were provided with accommodation. One said they often worked additional hours but this was their choice and there was no pressure for them to work overtime.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider’s governance systems and management arrangements were ineffective. Audits and checks were not being completed to monitor the service. Accidents and incidents were recorded individually but there was no system for analysing them to help identify any themes or trends. A medication audit had been completed 2 months prior to the inspection but this could not be located. An audit of care plans had recently been completed which identified multiple gaps in the records. However, work to address this had not started.

Monitoring systems and processes were not effectively or consistently followed. Prior to the inspection a manager had identified people were left without welfare checks for significant periods. On both days of the inspection visits we again identified several individuals who were at risk due to a lack of support. Action taken to address the issue had not resulted in improving people’s experiences.

People were not being weighed regularly, including people identified as being at risk due to poor nutrition. Some people had not been weighed since March 2025, including 1 person who had a pressure mattress which required setting in line with the person’s weight. This failing had not been identified by managers prior to the inspection.

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.

Following the inspection site visits and in response to the level of risk people were exposed to, partner agencies started working with the service to drive improvements. Feedback from partners supporting the service in the days immediately following the inspection to ensure people’s safety was that progress was slow. Although issues were highlighted there was a pattern of problems recurring indicating actions to address issues were ineffective.

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.

As stated throughout the report we identified, before, during and after the inspection, a theme of poor care practices being highlighted to senior staff, this being acknowledged and reassurances given, but the poor practices being repeated. For example, people were repeatedly left for unacceptably long periods without personal care checks or any meaningful interaction or engagement.

People’s needs associated with their dementia were not taken into account. The environment was not set up to meet these needs.