Ryland View 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 changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 64 (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.

The strategy aimed to do this by ensuring the happiness of each person was at the heart of the mission. The vision and purpose also focused on creating a relaxed, safe environment and providing connected meaningful person-centred activities as well as recognising their staff and supporting people’s emotional wellbeing. Feedback from people however was mixed some people telling us they could not take part in meaningful activities. One person told us they did not get involved because they were, “Not able to get out of bed so don’t get involved in activities.” Other people did tell us that they enjoyed the activities on offer, with one person saying, “The person that does the entertainment [staff member] is on holiday and they are wonderful.” The vision also aimed to create an environment where people and staff can feel safe, secure, reassured and protected. At the time of the inspection most people we spoke with reported feeling safe and secure, with one person stating, “Staff know what I like.” Another person told us they, “Feel comfortable and safe in bed”.

Staff we spoke with could describe the principles of the vision clearly as this was written on their ID badges. One staff member told us, “The first one is care, compassion, courage. There is a link between these values and the work the carers do you can see it.”

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. Although effective leadership systems were not fully embedded and the service had not had a registered manager since 1 August 2025, the provider had been actively recruiting managers to address gaps in leadership. Senior leaders had been providing support to the service to ensure staff were supported. Many of the people we spoke to provided positive feedback regarding the new manager stating that they were approachable and friendly.

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 in place which outlined how staff could raise concerns, this could be done internally or externally and anonymously if required. Staff we spoke with told us how they would raise concerns if they needed to and felt able to do so if required.

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.

Staff completed equality, diversity and human rights training, leaders offered reasonable adjustments for staff such as the ability to dictate notes reducing the need to manually do so which could be limiting for some people. The service offered flexible working agreements to support staff who may have additional responsibilities outside of work.

People and staff did not raise any concerns regarding equality, diversity and inclusion.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance systems were not consistently effective in identifying risks or ensuring timely action was taken to mitigate them.

Not all systems were functioning as intended with gaps in oversight and with inconsistent compliance with staff documentation. This meant that information used to reduce risk was not always accurate and therefore concerns could not always be identified or escalated appropriately. Clinical audit activity, including a weekly audit completed on 13 November, did not consistently demonstrate that care delivery was being monitored in sufficient detail. For example, pressure area care audits indicated that positional changes were planned and marked as completed; however, records relied on simple yes or no responses. Gaps were identified where documentation lacked sufficient detail to confirm whether repositioning had been carried out as planned, notably on 6 November and again on 14 November, limiting assurance that care was delivered in line with assessed needs.

Systems designed to identify areas of concern had failed to recognise ongoing issues with medication fridge temperature monitoring. During the inspection, records for the previous four months were reviewed and showed that the same temperature reading had been recorded repeatedly between 1 August and 24 November. This anomaly had not been identified through subsequent medication audits, indicating audit processes were not sufficiently effective in detecting or responding to inaccurate recording practices.

A review of audit documentation showed limited historical records due to changes in audit formats. While audits had been completed on several dates during this period, there was insufficient evidence to demonstrate that findings were consistently analysed or that appropriate actions were taken in response to identified issues. This meant we could not be assured that audit processes and quality assurance processes are effective.

In addition, a staff member reported that they were not always permitted to take breaks during their shift when raising this with their line manager, highlighting further discrepancies in management approach and staff support.

The provider understood their duty to collaborate and worked in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. When incidents or accidents occurred, internal systems prompted staff submit and work with the appropriate external stakeholder where required. We observed referrals being made to health professionals and we saw evidence of this in peoples care records which contained information and input from different professionals. For example, we saw that guidelines outlining the specific criteria for the covert administration of a medicine, the provider had identified that this may no longer be needed and was working with their GP to ensure this person’s support plan best reflected that person’s needs.

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.

Systems were in place to monitor incidents on a monthly basis to identify potential trends; however, these were not always used effectively to improve people’s care. For example, incident data identified a trend showing that a person was regularly becoming unwell, but it was not clear how this information had been used to inform changes to their care or reduce future risk.

There were also missed opportunities for learning following incidents. For example, after a medication discrepancy occurred, all staff involved in medication administration were required to repeat their medication training. While this addressed compliance, it did not demonstrate consideration of wider learning or identify whether other improvements could be made to systems or practice.

Although processes for reviewing incidents were in place, we were not assured that effective learning consistently took place. This meant the provider had not fully applied learning from the previous inspection or demonstrated that improvements had been achieved and sustained.

However, where learning was clearly identified, leaders told us this was shared across services to promote improvement. For example, following an incident involving a broken hoist pin, similar hoists were identified and removed from use, and replacements were sourced. This helped ensure people continued to receive care safely.