The Rookery 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 requires improvement. At this assessment, the rating has remained 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 people’s safe care and treatment and governance at the service. We have asked the provider to take action to improve 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.

The service did not have a clear and shared vision or strategy to guide its work. This meant while staff were committed and caring, there was not a strong, consistent direction that brought everyone together around shared goals. They did not always understand the challenges and the needs of people and their communities.

Staff told us they felt part of a positive team and were dedicated to supporting people’s wellbeing. This service was registered to provide specialist care for people living with dementia. However, the provider had not developed a clear approach which reflected the specific needs of people with dementia or the wider community. This included not involving people who used the service, their families, or staff in shaping the service’s future direction.

While staff generally understood their roles, there was limited evidence they were supported to see how their work contributed to broader goals. The provider had not created a culture where learning from mistakes was used to drive improvement. The service also lacked a clear plan to promote equality, diversity, and inclusion. The provider understood and acted on the duty of candour, which is their legal responsibility to be open and honest with people when something goes wrong.

There was no effective system in place to regularly check progress or measure how well the service was improving. This made it harder to know whether changes were working or if further action was needed. Although the provider had begun to make some changes, these were still at an early stage or had only started following our assessment and had not yet been fully embedded into everyday practice.

Not all leaders understood the context in which the provider delivered care, treatment, and support. They did not always embody the culture and values of their workforce and organisation.

Recruitment and succession planning processes were not sufficiently robust to ensure safe, inclusive, and values-driven leadership appointments. Some recruitment records were incomplete, with missing documentation. This raised concerns about the thoroughness of pre-employment checks. People who use the service, including those living with dementia and their families, were not consistently involved in recruitment decisions, limiting the opportunity to ensure leadership reflected the needs and expectations of those receiving care.

Leaders were not consistently aware of changes in regulatory requirements, and communication of updates to staff was inconsistent. This contributed to gaps in compliance and understanding across the service.

However, the registered manager was supported by the provider. The leadership team were visible and accessible, and staff felt able to approach them when needed. Staff told us they felt the management team had the skills needed at the service. One staff member said, “It’s how they are with the residents, how they are with the staff. They[managers]are hands on. They [managers] come out on the floor if you need help. They [managers] are always there for us and have always been good.”

The provider had fostered a positive culture where people felt they could speak up and their voice would be heard.However,most staff were not aware of whistleblowing processes or what Freedom to Speak Up meant in practice.

Staff described supportive relationships within the team and told us they could raise concerns with managers or the provider if needed. There was no evidence of a closed culture, and staff understood their safeguarding responsibilities, which helpedmaintainan open and transparent environment.Although staff felt comfortable raising concerns internally, they did not always know how to escalate concerns externally ifrequired. Thisindicatedgaps in staff knowledge and showed training and governance arrangements had not been fully embedded.

There were limited resources or information within the service to educate or remind staff about Freedom to Speak Up, and the provider had not fullyestablisheda proactive culture of learning from concerns raised. Although a whistleblowing policy was in place, it did not reference the updated terminology of “speaking up” and lacked a clear escalation pathway, including contact details for external bodies such as the CQC.

This meant while the culture wasgenerally positive, the provider could not be assured staff were consistently equipped to raise concerns safely and effectively, particularly when issues required escalation beyond the organisation.

The service had not taken sufficient steps to promote equality, diversity, and inclusion (EDI) within its workforce, and there was no specific evidence of embedded diversity or inclusion practices. While diversity and inclusion were recognised as important by some staff and leaders, this recognition had not translated into consistent or meaningful action. Leaders had expressed support for creating an inclusive and fair culture. There was limited evidence of efforts to improve equality and equity for staff, and no clear strategy or framework was in place to review and improve organisational culture in the context of EDI. There was insufficient evidence of proactive measures or targeted support for staff from excluded or marginalised groups.

Policies and procedures had not been routinely reviewed to tackle structural or institutional discrimination, and steps to remove bias from workforce practices were not clearly defined. Despite these shortfalls, staff reported feeling confident their concerns would be listened to and described positive team dynamics. One staff member said,“[management team] make sure staff get their regular days off so people [staff] have a break. They have always been open and check-up to see how you are. They are supportive. I have never seen or had any issues when it comes to too much stress.”

While staff did not report feeling excluded, the absence of a strategic and embedded approach to EDI meant the service had not yet ensured all staff were equally supported or that inclusive practices were consistently applied.

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.

While audits and reviews were being carried out, they often lacked the necessary depth to identify key risks and issues. In several instances, audits failed to detect the issues later identified by the inspection team. Even when concerns were noted, they were not consistently addressed or followed up with appropriate action. This indicated a lack of effective quality assurance processes and ineffective oversight.

All policies we reviewed did not contain sufficient detail such as relevant and correct legislation. For example, the equality and diversity policy listed things it said were protected by law, but some of them are not actually protected under the Equality Act. In addition, the whistleblowing policy which did not mention best practice of 'speaking up’ and did not have clear escalation process including contact information for CQC. Some polices had the wrong care home name or had not been recently reviewed. For example, the recruitment policy had not been reviewed since 29 July 2017.

Closed-circuit television (CCTV) video surveillance was in place in and around The Rookery Care Home. There was no risk assessment in place for this. The policy for having this in place lacked crucial information and did not mention the defined purpose for having it. There was no signage in the home to alert people and visitors to the fact they were being recorded and information on how to access the policy and privacy notice.

Although a matrix for staff training was in place, there was a lack of oversight to ensure staff had the right skills and knowledge to carry out their roles safely. This meant people were supported by staff who may not have had the necessary training. Competency records were not detailed enough to identify gaps. Records could not clearly evidence if staff had received training, or competency checks. Similarly records failed to evidence if staff had been safely recruited.

Systems, audits in place and risks to the health and safety of people had not been identified or addressed prior to our assessment of The Rookery Care Home by management. This demonstrated the ineffectiveness of the governance processes and meant they were not robust. The provider failed to identify risks associated with safe recruitment of staff, people’s environment, human rights, care, and support which placed people at risk of harm. The registered manager had started to introduce improvements following our assessment.

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 and the management team were open and transparent, and they collaborated with all relevant external stakeholders and agencies. The service worked in partnership with health and social care professionals to achieve good outcomes for people. Staff and managers ensured that where needed, timely and appropriate referrals were made to health and social care professions. External agencies told us they had no concerns about the service.

Some people were involved in getting to know their local shops and businesses. Staff at the service ensured people maintained links with community services which were important to them. Families were encouraged to visit and join activities. The registered manager told us about the Salvation Army band coming into the home and the local school choir, who were in the home during our assessment. They said, “it comes down to staff and family members. We have staff with children at the local primary school. We have a lady who comes from the Salvation Army who comes to see one of our residents. She brings in the band every year for us. The staff liaised with the teachers for us, and they bring the children down every year as well.”

This meant people benefited from links with the wider community, enhancing their support networks and wellbeing.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome, and quality of life for people. They did not always actively contribute to safe, and effective practice.

Concerns identified did not always lead to continuous improvement and sharing of learning across the home. Audits lacked detail and therefore failed to identify key risks and drive improvement.

The management team were responsive to our findings and were open to feedback and demonstrated they wished to make improvements at the home to improve people’s experience whilst living there.