Roberttown Care Home Limited

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 Inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider was in legal breach of regulations in relation to good governance.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not consistently demonstrate a shared direction or a cohesive staff culture aligned with the provider’s values and objectives.

Not all staff were aware of the service’s aims or the direction of care delivery. Observations of staff practice during the inspection supported this, showing inconsistency in how care was provided and how staff engaged with people.

The overall culture within the home was not fully reflective of the provider’s intended values. The reliance on agency staff had placed additional pressure on the permanent team, which impacted morale and continuity of care. This strain contributed to a fragmented working environment where shared goals and consistent standards were not always upheld.

There was no documented evidence of regular discussions or meetings between the provider, leadership, and staff to ensure a clear and collaborative understanding of the service’s direction.

While some staff were committed to delivering good care, the absence of a clear, shared direction and team cohesion meant the service did not always operate in a way that consistently upheld the provider’s vision or best supported people using the service.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

There had been no registered manager in post for over 156 days, and during this time, leadership arrangements had been unstable. Leaders who had been in place failed to take prompt or effective action to address concerns, including those related to a poor staff practice and service shortfalls. This lack of timely leadership intervention contributed to a decline in the quality-of-care people received.

There was no evidence of strong oversight or accountability to ensure improvements were being driven forward. Systems and processes designed to monitor care delivery and support staff were not being effectively implemented. Supervisions were not routinely carried out, meaning staff were not consistently supported, guided, or held accountable for their practice. In addition, there was no clear process in place to follow up on training to check whether staff had understood and embedded their learning into daily practice. This weakened the service’s ability to ensure staff were competent and confident in delivering safe, compassionate care.

The absence of capable and compassionate leadership had a direct and negative impact on the culture of the service and the wellbeing of the people living there.

People did not always feel they could speak up and that their voice would be heard.

Staff told us that they generally felt able to speak up; however, recent changes in management had negatively impacted their confidence in doing so. Feedback from staff was primarily focused on a perceived lack of support from leadership, contributing to low morale within the team.

During the inspection, no staff member was able to provide an example of when they had utilised the ‘Freedom to Speak Up’ policy. While staff demonstrated confidence in reporting accidents, incidents, and falls, they were less forthcoming in reporting observed unsafe practices or concerns related to care standards.

Additionally, there were no complaints recorded in the service, and as such, there was no available evidence of investigations or learning from complaints.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The recruitment process demonstrated a fair and equitable approach, resulting in a workforce that reflected diversity. Staff reported feeling they were treated fairly and equitably in the workplace, and no concerns were raised regarding discrimination or unfair treatment.

However, we did not observe any formal processes in place to actively promote workforce well-being or inclusion beyond recruitment. Additionally, the recent staff survey had an extremely low response rate, with only 2 staff members participating, which limited the ability to capture a representative or service-wide view of staff experience and inclusion.

We found that the governance systems and processes in place were ineffective and had not been consistently implemented.

Where audits had been undertaken, there was a clear lack of action taken to rectify and address identified shortfalls. For example, 2 of the quality audits highlighted 170 outstanding actions, the majority of which remained unaddressed at the time of assessment.

Key shortfalls identified during the assessment included insufficient monitoring and review of accidents, incidents, falls, behaviour monitoring charts, and weights; inadequate staff supervision and lack of regular compliance checks; absence of provider-level audits such as DoLS oversight; poor oversight of care records and risk assessments; and non-compliance with the provider’s manual handling and admission policies.

The previous manager had also failed to meet their regulatory responsibilities by not submitting required notifications and safeguarding referrals in a timely manner, due to a lack of oversight. These issues were retrospectively reviewed and addressed by the interim manager prior to inspection.

The new interim manager had begun taking action prior to the inspection and continued to make improvements following our assessment and feedback. The provider has been responsive to the findings of the inspection and has introduced new systems and processes, which are now in place to drive improvement. However, these changes require time to become fully embedded before sustained improvements can be demonstrated.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

People living at the service and their families expressed concerns about a lack of collaboration with external organisations. There was no evidence that staff actively supported people to integrate into the wider community, such as facilitating attendance at local dementia cafés or community groups.

Furthermore, there was no formal system in place to gather or share feedback from people, relatives, or staff, and there was no evidence of learning being shared through meetings. This lack of engagement and collaboration with external partners and the community limited opportunities for people to maintain social connections and benefit from wider community resources.

One person did confirm they attended church but it was unclear whether this was facilitated by relatives rather than being supported by staff in the service.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system.

There was no demonstrable evidence that lessons had been learned from accidents, incidents, or falls, due to the absence of meaningful action to review and analyse these events for trends, patterns, or opportunities for improvement. Quality assurance systems were either inconsistently applied or ineffective, which limited the service's ability to drive improvements that promoted equity, positive outcomes, and enhanced quality of life for people using the service.

We found no evidence that learning from safety events was shared or embedded at a provider-wide level to inform and improve practice. This limited the provider's ability to deliver safe, responsive, and high-quality care.

However, following feedback from this assessment, the provider advised that new systems and processes had been developed and were ready for implementation. These were intended to establish a structured, provider-wide approach to learning and the dissemination of lessons to support continuous improvement.