Ryhope Manor 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 inadequate. 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 relating to monitoring the quality and safety of the service and failing to display the rating from the last assessment.

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.

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.

During the last assessment the provider did not have an effective strategy to develop a shared direction, culture and vision to ensure high quality care was provided. Regular resident and relative meetings were now taking place to discuss the service and the provider sent out surveys to try and gather views. However, people and relatives fed back they were not involved in ongoing care planning for people, to meet their individual needs.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Following our last assessment, the provider and management took action to address some of the issues identified and formulated an action plan to address the outstanding areas. However, some shortfalls were still apparent in the home around the quality, safety and governance of the service provided.

Despite these shortfalls, people, relatives and health professionals spoke positively about the registered manager. A health professional told us, “[Registered manager] does care a lot, and she knows the residents really well. Her heart is in the right place.”

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

The provider encouraged staff to share concerns and speak up. Staff told us the registered manager was approachable and supportive. Staff were confident any concerns they raised would be acted upon. A staff member said, “I can raise issues or make suggestions with management. I've found that they listen and provide feedback, which helps me feel supported and valued as part of the team.”

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. Since the last assessment appropriate improvements had been made to recruitment practices, to ensure they followed the provider’s recruitment policy and reflected equality, diversity and inclusion.

Staff told us they enjoyed working at the home and felt supported. A staff member said, “I feel well supported because there's always someone to go to for guidance. Regular supervisions and appraisals help me reflect, get feedback, and improve my skills, which makes me confident l am providing safe, high-quality care.”

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 continued to lack an effective quality monitoring system to ensure all regulatory requirements were met. The registered manager and senior management carried out a range of audits and checks and had implemented further checks following the last assessment. However, they had failed to identify shortfalls found during this assessment and repetitive breaches of regulation. This meant further improvement was required to ensure governance systems were effective and thoroughly embedded, to ensure people were safe and received high quality, consistent care.

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.

Since the last assessment the provider was working with external agencies to improve the service, including the local authority and health professionals and some improvements had been noted. However, further time was required to fully embed improved practices.

People told us they were supported to access health and social care services. Feedback from health professionals demonstrated relationships with care staff required further development, to achieve a seamless approach. A health professional told us, “We don't know the care staff by name and wouldn't know who to speak with to ask for help with anything.”

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, effective practice and research.

An effective system was still not in place to identify and share lessons learned. There was limited evidence safeguarding concerns, accidents or incidents were reviewed and monitored to identify any trends or themes and lessons learned, and to ensure appropriate action could be taken to minimise the risk of any reoccurrence.

The provider had made some improvements since the last assessment, however there were recurring shortfalls identified that needed to be addressed. The provider took immediate action to rectify some of the issues identified during the assessment.