Red Rose Care Community

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 remained requires improvements. 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 at the service.

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 had a clear shared vision, strategy, culture but did not always have effective engagement. For example, there had been a number of engagement meetings with people, relatives and staff. Feedback from these meeting were not always actioned and similar concerns kept being raised at multiple meetings. This meant there was not always a meaningful way for people to involved with developing and shaping the service. The management team acknowledged our feedback told us they would improve and were committed to delivering care in line with their vision

The management team did understand the challenges and the needs of people and their communities. Staff had completed training in equality, diversity and human rights.

Whilst the management team and staff were compassionate about ensuring people received safe, high-quality care. However, due to the concerns found during the assessment we were not assured that managers always had the knowledge needed to ensure effective care. For example, people did not have care plans in place for known health conditions such as diabetes. The management team throughout our assessment were open and honest and had taken immediate action regarding concerns we raised. The clinical lead staff member was experienced and knowledgeable. People and professionals spoke highly about the work they did. One professional told us, “The overall management has improved considerably, and since the appointment of the Clinical Lead, there have been numerous positive changes implemented."

The provider fostered a positive culture where people felt they could speak up, and their voice would be heard. There were processes and systems in place for people and staff to have the freedom to speak up. Staff were confident to raise concerns, and confident that the registered manager would take action. Notes were kept from meetings that had been completed and the records showed staff acted with openness and transparency as concerns were raised regarding food rationing and management action was taken immediately to address this. Where staff had raised concerns, the registered manager logged these as complaints for transparency and honesty. When something had gone wrong, people receive a sincere and timely apology and were informed of the actions taken to prevent the something happening again. For example, where we found concerns and this had impacted people, the provider told us they would ensure all the people affected and relatives would receive an apology and information on what action they had taken.

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. The provider recruited a multicultural staff team including staff from overseas. The management team treated all staff equally and all staff were provided with the same rights. The staff team had opportunities to raise concerns through staff supervisions, meetings or handovers between shifts. Staff had completed health questionnaires before they started working. This provided the management team with an opportunity to identify any reasonable adjustments that may be required. The provider had an equality, diversity and inclusion policy in place to provide all staff with clear guidance.

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. There were gaps within the management structure that had impacted the oversight of the service. For example, the deputy manager had moved to another home within the organisation. The post had been filled by the clinical lead. However, they were unable to fully start their role as their current role was not covered. This meant one staff member was covering two roles which was not effective.

Whilst there was a range of audits completed, these were ineffective in identifying risks, concerns and required improvements. For example, the audits did not identify the concerns and risk we found, in relation to staff deployment, staff training, medicine management, risk management, lack of detailed care plans, risk assessments and outstanding health and safety actions. The gap in management and ineffective oversight, meant people were at risk of receiving unsafe care. The provider was receptive to our feedback and sent an action plan addressing the most serious concerns.

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. Whilst the provider had good relationship with all professionals. We found not all feedback, concerns and required actions raised by health professionals were completed. For example, actions such as blood pressure readings were requested and this was not always completed by the home. This meant services could not always work seamlessly for people.

The registered manager had a contract monitoring visit from the local authority where they had met all their contractual obligation. The NHS medicine team had visited, and actions were identified. The registered manager completed the required actions and shared evidence; they had completed them. This meant there was sharing of information and collaborative working for improvements.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. Whilst the provider had an external company complete a mock inspection to learn and make any necessary changes. The provider had not always learnt from previous CQC inspections to ensure their own systems and processes had improved to identify risks internally. Staff meeting notes and staff supervision records showed learning was not always shared or discussed. Feedback that had been obtained by people and staff was not used to make the necessary changes; this was missed opportunities to improve the service. The provider and manager told us they were committed to make the necessary improvements for the people who live at Red Rose Community Care.