Rathgar 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 Good. At this assessment the rating has changed to 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 good governance.

This service scored 61 (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 based on transparency, equity, equality, human rights, diversity and inclusion, engagement, and understanding the needs of people and their communities. However, this vision had not consistently ensured that effective governance was central to the service’s direction.

The provider’s vision and values were known by staff and formed part of staff induction. Some positive feedback was received from people and staff about their experience of the service. For example, one person told us, “It’s wonderful here – smashing – we are well looked after,” and another said, “There is a good crew of staff night and day.” A member of staff told us, “I would let my relative live here.” However, this positive feedback of the service culture was not always reflective of consistent systems and leadership oversight in relation to governance.

The provider had a vision for the future, including plans to grow and develop the home. However, work was required to clearly define the strategic direction in relation to governance and quality assurance and how this would be strengthened. At the time of the assessment improvements were underway. However, they had not yet been fully embedded into the provider’s overall direction to evidence a sustainable approach to governance.

Leaders understood the context in which the provider delivered care, treatment and support. They embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively, or they did so with integrity, openness and honesty. However, the leadership of the service had not always been consistent in relation to governance.

The provider’s nominated individual and registered manager were well known and respected by people, relatives, staff and external professionals. In relation to the registered manager, people told us, “This [registered manager] is brilliant,” and, “[Manager] is lovely – you couldn’t get anyone better.” We were also told by staff, “The [manager] door is always open,” “You can go to [manager] with anything and [manager] will help you, it doesn’t have to be about work,” and, “[Manager] is nice, helpful and supportive."

In relation to the nominated individual, a person told us, “On a Monday and a Thursday, [nominated individual] comes and sits with me and talks to me – [nominated individual] is nice”. The positive feedback was echoed by staff who told us, “[Nominated individual] is very involved – it is very good [they] are approachable,” and, “[Nominated individual] has a good bond with residents”. A final member of staff told us, “[Nominated individual] genuinely wanted the best for staff and residents.”

The feedback we received demonstrated that leaders were compassionate and inclusive.However, we found that the leadership of the service had not always been consistent in relation to governance. This lack of consistency had led to the concerns that we identified during our assessment.

We shared our feedback in relation to our findings during the assessment. Leaders of the provider were receptive to our feedback and told us the actions they were taking to make improvements.

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

The provider had a whistleblowing policy. Staff told us they were able to raise concerns with the registered manager and provider without fear and were confident that action would be taken to address concerns.

The provider had implemented an external confidential reporting service so people were able to speak up anonymously if required.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by promoting equality and equity for people who worked for them.

The provider was committed to equality, diversity and inclusion, and their workforce reflected this. For example, their job adverts contained an equality statement.

The provider told us they were a values-led employer, and this was reflected in the recruitment of new staff joining the service.

Staff benefits included gift vouchers at Christmas, staff parties, pizza for those who worked shifts instead of attending the parties, free meals, a pension and a refer-a-friend scheme.

The provider did not always have clear responsibilities, roles, systems of accountability or effective governance. They did not always act on the best information about risk, quality and performance.

The provider had governance systems and processes in place; however, these had not identified all the areas for improvement we found during the assessment.

The provider held a weekly management team meeting where key areas of governance were discussed, including call bells, maintenance, kitchen, cleaning and staffing.

The provider had a schedule of audits that were completed by a member of the leadership team, including care plans, medicines, infection control, catering, and health and safety. However, audits had not identified all the concerns that we found during the assessment.

For example, the health and safety audits found all paths were free from damage and had not identified the need to replace the ramp at the rear of the building. Audits and leadership oversight had not identified that people were living at the home without adequate care records or that a serious injury statutory notification had not been submitted to the Commission.

The registered manager and deputy manager told us they were working together to improve governance arrangements. For example, improvements to care plan audits. We were assured the provider would implement changes to improvement governance practices.

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 to support improvement.

The provider and registered manager told us they were board members of the Northamptonshire Association of CQC Registered Care Providers (NORARCH) and also attended local authority forums.

The registered manager was chair of the Northamptonshire Registered Managers Network and was passionate about developing relationships that benefit people and colleagues at Rathgar and beyond.

There was a visiting professionals survey carried out in 2026 that demonstrated the positive experiences professionals had with the home.

The registered manager attended quarterly updates from a local hospice to support end-of-life care.

The provider demonstrated a commitment to continuous learning and development to improve the service and people’s quality of life.

For example, the service was taking part in a research study through the ENRICH network. The network helps connect care homes with researchers, enabling studies that improve the lives of residents and staff.

While there was a commitment to learning and improvement, and the provider had established a development plan for the service, we found that required improvements had not always been identified or acted on.

We found the provider needed to consider how to strengthen their governance processes to enable learning, improvement and innovation, including the introduction of an effective service improvement plan.

The provider assured us they had reflected on our findings and told us the immediate actions they were taking, and how they would sustain these for the future.

We returned to the service several times during our assessment. The provider told us about immediate improvements that had been made. While we were assured the provider was acting on our feedback, governance processes required embedding.

We will check on the implementation of these plans at our next assessment.