Richmond Village Witney

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. We found one continued breach of the regulation in relation to good governance. Governance systems and audits were not always effective in identifying or addressing areas for improvement.

This service scored 54 (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 and culture, but improvement was required to ensure it was embedded throughout the service as the culture of staff and the feedback received from staff meant we could not be assured the culture of the home was always positive. The home manager spoke of a positive direction in the home. Some staff told us they could see improvements had been made over the last few months, however they also felt communication was not always effective. The new home manger was working on ensuring all staff had access to regular supervisions, handovers, and team meetings to maximise setting the culture, staff felt positive about the direction of the service.

The provider had inclusive leaders, but they required more time, knowledge and experience of the service to ensure high standards of care were consistently achieved. There was a new management team in post, who were aware of issues and priorities within the service and were working towards improvements and changes to systems and processes. Staff felt the home manager was supportive and were confident over time changes would be implemented to support better relationship working within the teams. However, some staff felt they didn’t always feel valued by the staffing team, and not all relatives and people who used the service knew who the manager was. The home manager held monthly relative meetings, and produced newsletters to ensure people knew who to contact.

Staff felt able to speak to the home manager directly about any concerns. Staff meetings had recently been reintroduced. Most staff we spoke to who attended the meetings reported positively on these. However not all staff we spoke to felt able to raise concerns, or that they received feedback following concerns raised. Staff knew about whistleblowing policies in place.

The provider valued diversity in their workforce. They were working towards an inclusive and fair culture by improving equality and equity for people who worked for them. We received mixed feedback from staff about feeling valued, we heard staff felt the culture was changing to be more positive. The home manager told us their workforce was important to them, and action had been taken to ensure the service has regular staff and there was a low usage of agency staff.

The provider was working on implementing clear responsibilities, roles, and systems of accountability. Audits were completed monthly by leaders but failed to identify gaps we found during our assessment. For example, sufficient risk assessments and mental capacity assessment were not in place to mitigate risks to people, and people’s documentation contained conflicting information. The service completed surveys, analysing results to see where improvements were needed, and meetings with relatives and staff had been reintroduced. However, there was no evidence actions following these meetings were documented and actioned in order to ensure concerns were looked into. The home manager assured us new systems would be put in place to ensure oversight of these meetings. There were systems in place to monitor call bell waiting times, and falls analysis. However, there was limited evidence this was looked at in conjunction with staffing levels to monitor for themes and trends.

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 about partnerships and the positive impact partnership working had on people care. People told us they had seen a variety of healthcare professionals and staff would support them to appointments if required. Professionals provided feedback about the service, we heard there had been some delays in appropriate care being sought, we also heard professionals experienced good communication with the service and staff were honest and open about safety concerns which were generally raised appropriately.

The provider's processes to ensure continuous learning, innovation and improvement across the service were not always effective as they were not robust enough to ensure improved quality standards. Further improvements were required to evidence the provider was monitoring the service and best practice was embedded into the practice of the home. For example, although there were daily handovers in place and lessons learnt documentation in place, these were not always documented, or did not contain enough information such as the incident or the action to learn from the incident.