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 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 in relation to good governance.

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

The culture within the home was not fully transparent and cohesive. The manager told us they were working hard to address this, by being accessible to staff and encouraging collaborative communication. Staff were mostly receptive to the new manager, although there was still some lack of confidence expressed.

Supervision meetings had improved in consistency to give staff opportunities to be heard, and the manager told us she encouraged staff to take the lead in these discussions. Staff said they welcomed this and felt able to make suggestions. Staff told us they wanted to provide good quality care although spoke about some workload pressure and inequity in team contributions. As a result, the culture across the service was not yet fully embedded and required further ensure consistency.

The wider management team were supportive of the manager in helping to shape, improve and embed a shared direction and culture.

Leaders demonstrated the skills and integrity required for their roles; however, improvements were needed to ensure consistent visibility, effective follow-up of concerns and embed changes.

There had been changes to the leadership team since the last assessment and the new manager had come into post with a challenging workload and many issues to address which they were still working on. They had a clear goal for improvements and were beginning to see positive results from their work. For example, improved stability in the staff team, scheduled supervision meetings, staff training and care planning reviews.

Systems and processes to monitor care delivery and support were in place, but not always effective or thorough enough to secure the widespread improvements needed since the last assessment.

The manager showed appropriate experience and knowledge, and demonstrated responsiveness in their approach to complaints and staff investigations raised through the assessment process.

People felt they could speak up, and were confident that their voice would be heard.

Staff understood how to raise concerns, and were aware of the processes available to them. Leaders encouraged the reporting of concerns and poor practice.

Staff said they would be confident in raising concerns, and were assured action would be taken as a result.

Appropriate processes were in place to support staff in speaking up where they may have concerns.

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.

Recruitment processes were fair, and the staff team reflected a diverse workforce. Staff understood equality, diversity and inclusion and felt able to recognise and respond to discrimination where required.

Policies and training were available for staff to reinforce their knowledge and understanding.

Governance systems and processes were not fully effective in identifying shortfalls or driving improvement. Although a range of audits and monitoring tools were in place, these were still not robust or embedded to provide clear oversight and ensure risks were acted upon.

Audits did not sufficiently identify key risks or provide accurate analysis to inform action. Medication audits had failed to pick up on the issues found on assessment. Where they did identify some concerns, we saw these were repeated over 3 subsequent audits. Internal and external quality reports showed some audits stated as compliant, yet the content within these clearly identified areas in need of improvement.

Poor recording and limited monitoring of distressed behaviours meant the provider did not have sufficient oversight, increasing the risk of inconsistent support for people. Records were not always accurate or fully completed, and information was not consistently stored securely to protect people’s confidential personal information.

The review of accidents and incidents was not always carried out in a timely way, with some delays between staff reporting and management oversight. The manager was aware of their regulatory responsibilities to submit statutory notifications to CQC, however it was not always clear from the accidents and incidents data, this was happening consistently.

A service improvement plan was in place and there were some signs of improvements since the findings of the last assessment. There was evidence of clearer internal communication and management presence in meetings and daily huddles. Much of the required changes were still work in progress and identified at the last assessment.

Overall, governance arrangements still required strengthening and embedding to provide sufficient assurance of quality and safety.

The service had started to build community links, with further development needed to maximise opportunities for people.

The manager told us they were considering ways to improve the outside activities and community links. They worked in partnership with a local volunteering team and had taken part in ‘Roberttown in bloom’, planting outside in the community.

Some people were supported to attend the community hall and the manager was aware of the need to ensure everyone had the same opportunity as it was usually the same people who joined in each time.

The provider was improving their focus on continuous learning, innovation and improvement across the organisation and local system. However, creative approaches to delivering equality in experience, outcomes and quality of life were not yet in place, and the provider did not always actively contribute to safe, effective practice and learning.

There was some evidence that learning and innovation were beginning to be embedded. Systems for recording information were in place, but these were not always accurate or used proactively to review practice, identify trends or drive improvement.

Audit and governance processes were sometimes used to support reflective learning; however, there were missed opportunities to ensure learning from incidents or monitoring led to improvements in practice. Overall, systems and frameworks were in place and beginning to support improvement, but were not yet used consistently or effectively to fully embed continuous learning, innovation and sustained improvement across the service.