The RedHouse 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 due to ongoing shortfalls in governance and inconsistent leadership that affected the service’s ability to deliver safe, person-centred care.

Governance systems were not robust. Audits failed to identify key risks, such as environmental safety issues, inconsistent use of the IDDSI framework, CCTV usage without consent, and gaps in people’s future care planning. These shortfalls limited the provider’s ability to assess, monitor and improve the service. However, feedback from people using the service, relatives, and professionals identified the service was improving.

The provider has started to make changes, but these had not yet been embedded or led to sustained improvements. There was a breach of the regulations 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 did not yet have a fully embedded shared vision, strategy, or culture underpinned by principles of transparency, equity, human rights, diversity, and inclusion. While there were positive developments underway, leaders had not consistently demonstrated an understanding of the challenges facing people using the service or their local communities. The service was undergoing a period of cultural transition. The home had experienced multiple changes in management in recent months, contributing to instability in leadership. A new acting manager had been appointed, and a deputy manager was being recruited. The changes being made needed further time to embed.

Staff feedback reflected a workforce in the early stages of cultural recovery. The Majority of staff described a more open, approachable, and supportive environment under the current leadership. However, a minority of staff described the culture as still being divided or influenced by past factors. This variance in perception had resulted in inconsistent staff engagement and created risks to team cohesion.

The provider and acting manager recognised the fragmented culture and were actively working to address it. Steps taken included increased leadership presence in the home, clearer communication channels, regular team meetings, and staff feedback mechanisms. Staff surveys and one-to-one supervisions were being used to identify areas for improvement and reinforce values-led practice.

People living in the service, along with relatives and professionals, described a more relaxed and inclusive atmosphere, with greater staff attentiveness and clearer communication. However, the service had not yet achieved a consistently shared and embedded culture. Leaders had begun to demonstrate a clearer sense of direction, but this had not been fully translated into practice across the whole staff team. The provider had begun to take positive, proactive steps to build a more inclusive and values-led culture, but these efforts were still at an early stage.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not consistently promote a fair and inclusive culture. While policies were in place to support diversity, wellbeing and staff engagement, the experience of staff was variable, and not all felt supported or treated equitably. Although policies promoting equality, anti-discrimination, and staff wellbeing were in place, the culture was not consistently experienced as inclusive by all staff. Training in diversity, harassment, and bullying had been completed by most team members, and support services such as mental health first aid and independent HR advice were available. However, not all staff felt these measures translated into day-to-day practice.

Some staff told us they felt valued and supported by the new leadership, with signs of a more open and positive working environment. Others, however, described ongoing cultural issues, including tensions among staff and trust in systems and processes. There was limited evidence that the provider actively sought feedback from underrepresented staff or engaged directly with those from protected characteristic groups to understand their experience of inclusion. As a result, not all staff felt heard or involved in shaping the culture of the service. However, there was no evidence that any inequalities or divided culture had directly impacted the care provided to people using the service.

People were supported by a diverse workforce, and we observed respectful, inclusive practice during the inspection. The provider had appropriate policies in place, but these were not consistently embedded into practice. The acting manager and provider’s compliance team were aware of the cultural divisions and had begun taking steps to address them. This included strengthening supervision, improving communication, and rebuilding trust. However, progress was still at an early stage, and further work was needed to ensure all staff consistently felt respected, included, and treated fairly.

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. There were significant shortfalls in governance, oversight, and accountability across multiple aspects of the service.

We found ongoing concerns related to environmental safety, CCTV consent, advanced decisions and end of life care planning, and staff management.

Key safety measures, such as fire door maintenance and call bell functionality, were either missing or poorly monitored. Environmental risks included damaged fire doors, blocked corridors, unsecured windows, and the use of unsafe or unsuitable stairgates. Of particular concern was the lack of monitoring or restrictions around stairwells in areas accessed by people living with dementia. These areas posed a high environmental risk, especially for individuals who may be confused, have poor safety awareness, or mobilise unaccompanied. Although no incidents had occurred at the time of inspection, the provider had not appropriately recognised or managed this risk, and mitigation in place was ineffective. While some environmental issues were addressed during inspection, others required urgent review and external expertise to ensure safety.

The management team deployed care staff to cover kitchen duties despite some lacking confidence or competence in preparing modified diets according to the International Dysphagia Diet Standardisation Initiative (IDDSI). This posed a significant risk to people requiring specialised nutritional support. Furthermore, staffing shortages were exacerbated when the provider did not to deploy additional staff or agency cover during kitchen staff absences. This impacted both kitchen operations and the timely delivery of personal care to people. This shortfall in staffing extended to care duties, with feedback and care records highlighting delays in meeting immediate personal care needs, such as continence support. These delays sometimes lasted for extended periods without clear reasons or escalation to leaders. These delays were not identified through routine audits or monitoring systems of day-to-day care delivery.

Care planning did not consistently include key person-centred elements, such as advanced decisions and end-of-life preferences. These compounded risks related to personalised care and wellbeing. These systemic governance failings directly impacted people’s safety, dignity, and rights.

The provider was responsive to feedback and took some immediate actions. These included initiating a fire safety review by an independent contractor, improving the safety and accessibility of key areas of the environment, implementing an on-call rota, starting staff retraining, and beginning the development of future planning documentation. Despite these positive steps, the provider had not previously identified or addressed these risks, and robust systems to assess, monitor, and mitigate them were not in place. These shortfalls in the assessing, monitoring and improving the service potentially placed people at risk of harm. This was a breach of legal Regulation for Good Governance.

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 for improvement.

The acting manager regularly attended local provider forums, including Hampshire care manager meetings, and maintained open and transparent communication channels with families, healthcare professionals, and community agencies. This proactive engagement helped to address issues promptly and ensured that care plans were informed by a wide range of expertise. Staff and people were involved in discussions about shared learning through regular team meetings, ‘residents’ forums’, and feedback sessions. These opportunities encouragedcollaborative problem-solving and supported continuous service development that reflected the needs and preferences of the people living at the home.

External professionals spoke positively about their experiences working with the service. One healthcare professional commented, “The service works well with me, and all the staff are very approachable.” Such feedback highlighted the service’s commitment to maintaining strong, professional relationships, which helped to facilitate coordinated care and ensured people could access a broad range of community and healthcare resources as needed. Overall, the provider’s inclusive and open approach fostered an environment where partnership working flourished, benefitting both residents and the wider community.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. Several initiatives had been introduced to enhance care quality, staff development, and operational efficiency. For example, prior to the inspection, the service had begun upgrading the emergency call bell system to ensure more reliable and timely responses to peoples’ needs. The implementation of electronic care records was underway, with ongoing refinements to improve accessibility and enable more responsive and personalised care planning.

In response to feedback from people using the service, key policies were reviewed and adapted into easy-read formats, supporting better understanding and engagement. Meeting records reflected regular team discussions focused on identifying service improvements, and staff were actively encouraged to raise concerns and contribute new ideas. These developments had a positive impact on the experiences of people using the service. Enhanced communication and more detailed care planning supported a truly person-centred approach, while staff reported feeling more supported in their roles and better equipped to develop their skills.

Relatives and external professionals noted a marked shift towards a more professional, proactive, and responsive culture within the home. Looking ahead, the provider had plans to further embed training and ensure staff were confident and competent in using new systems and technologies. The ongoing implementation of improved technologies and clearer communication processes underpinned a positive culture of learning and continuous improvement, directly linked to better care outcomes for people.

The provider had a strong commitment to growth and excellence. They were prioritising staff development, innovation, and collaborative practice to have a positive impact on the experiences of people using the service.