Ridgeway Court 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 new provider. This key question has been rated 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 provider was in breach of legal regulation in relation to governance as systems were not always effective in identifying shortfalls to ensure these were addressed.

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.

A clear shared vision and culture, understood and supported by staff, had not been embedded within the service.

The provider had not yet fully embedded a clear vision, strategy or set of values, aims and aspirations for the service which staff knew about and followed. Staff when asked, did not know what the vision of the service was. When asked, the provider told us the vision was as shared with CQC in their application when the provider took over the service in 2024. This being to create a family-home environment focused on personalised care, dignity and improving standards across the service.

The provider did advise us of the challenges they had faced with the culture within the home and trying to embed changes. Work is ongoing to implement proposed improvements across the service.

Leaders demonstrated the skills and integrity required for their roles; however, further improvements were needed to ensure consistent visibility, effective follow-up of concerns and to embed changes.
 

The provider told us about the journey they have had since taking over the home and the many challenges they faced, including with the environment. The provider told us they had invested in a lot of time initially alongside the staff to stabilise the home and to begin the process of improving the standards of care. The provider told us they were dedicated and invested in driving improvements in the home. As previously stated in this report the environment and standards of care were not always meeting the required standards and improvements plans were in place to address this and to develop the service.

Most relatives told us they were consulted about their relative’s care. Staff told us the manager was visible, accessible and approachable.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People and relatives told us they felt able to speak up when they were not happy with things. One person told us, “I am not afraid to say what I think even to the management.”

Surveys were sent out to people, relatives, professionals and to staff to obtain feedback about the home. The electronic signing in system also gave visitors an opportunity to provide feedback following their visit to the service. This system was updated following our feedback to include making visitors aware CCTV was in use in communal areas.

Staff told us they felt able to speak up and raise any concerns particularly in relation to people’s care. Staff were aware of the whistleblowing procedures in place which supported them to escalate concerns confidentially. Most staff felt able to share ideas and feedback in team meetings, however some staff felt their views would not be valued or listened to.

We saw there was a ‘You said we did’ board displayed in the corridor. This gave examples of actions taken in response to feedback previous obtained. For example, developing a new summer menu, increasing external entertainment, and redecorating the home.

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.

Most of the staff felt they were treated equally. The dynamics and culture within the home were being changed with the introduction of new staff and some existing staff leaving the service. Staff felt the manager considered and accommodated their individual circumstances when planning shifts. People with protected characteristics felt supported.

Governance systems and processes were not fully effective in identifying shortfalls or driving improvement. Although a range of audits and monitoring tools were in place, these were still not robust or embedded to provide clear oversight and ensure risks were acted upon.

The home does not currently have a registered manager. An interim manager is covering the role, who is supported by a deputy manager. The provider is currently recruiting to this position.

The provider’s own governance systems had failed to identify people were not always receiving effective care and therefore prompt action had not been taken to make improvements.

Quality assurance audits had been completed. However, these had not always been effective in identifying the shortfalls we found at this assessment. For example, the way people’s consent was obtained, completion of mental capacity assessments, lack of involvement by people to make choices about their care, staff and management lack of knowledge about key statutory guidance, and lack of meaningful activities.

We also found several reportable incidents had not been reported to CQC as required by the regulations. This had not been identified by the provider. The manager has retrospectively submitted these for the last 6 months.

Where the provider’s audits did identify concerns for action, they did not always bring about timely improvements. For example, environmental issues such as damaged chairs, damaged blinds, and damaged flooring. The manager and provider were responsive to some of the concerns raised and started to make improvements during the inspection.

As previously stated, action plans were in place to improve the systems in the home. This included reviewing and improving the care records in place due to gaps, and the lack of person-centred information. Daily records we reviewed were task focused, brief in detail and did not reflect people’s well-being. Improvements in the recording of these had been identified and included in the action plans.

The provider’s statement of purpose had not been updated since they took over the home. Therefore, it did not reflect the needs of the people living in the home and how these would be met. For example, the provider supported people whose needs included learning disabilities, and mental health needs.

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.

The manager and provider worked in partnership with partner agencies to improve the standards in the home. This included the local authority and a fire consultant. The provider and manager shared information with partner agencies in response to safeguarding and complaints raised about people’s care.

The provider was working towards a culture focused on continuous learning, innovation and improvement; however, this had not yet been fully embedded. Creative approaches to delivering equality in experiences, outcomes and quality of life were not yet fully encouraged.

The manager and provider were responsive during our inspection and told us they were taking learning from this inspection, and we saw our feedback was added to the action plans in place.

The manager and provider shared with us several ideas of how they wanted to improve people’s experience. These included developing the activities provision and improving the mealtime experience. The manager told us they had started to work on care plans and risk assessments to make them more person centred. However, time was needed to complete this work and staff practices to bring about the required improvements and embed them into practice.

The provider told us how they had already invested in the home with the introduction of solar panels, and a new lift was planned to be installed. An extension was planned for the summer to improve the environment, and a refurbishment plan would commence to improve communal areas, and bedrooms. Plans were in place to landscape the garden area to enable people to access this safely. The provider told us they would review best practice guidance to ensure the environment met the needs of people who lived with dementia.