Rhodsac 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: 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 a legal regulation in relation to governance at the service.The governance systems in place were not effective in identifying areas for improvement and the provider had failed to act to maintain the service to a safe standard. The safety and quality of the service had deteriorated since our last assessment.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

The provider acknowledged that improvements needed to be made to the oversight and governance of the service. However, insufficient action had been taken since our last inspection to maintain appropriate standards at the service.

The provider had failed to ensure governance processes were effective. The systems in place had not resulted in the service being maintained to a safe and appropriate standard. Audits were not carried out in line with policies and procedures; areas for improvement were not identified, and improvements were not made when required.

The provider failed to protect people from the risks associated with the upkeep of the environment. People were at risk due to the failure to have systems to record, monitor, evaluate and mitigate the risks associated with fire safety, water, hot surfaces and the external areas of the home.

There was poor governance and a lack of ongoing monitoring of care documentation. People's care plans and risk assessments contained inaccurate and incomplete information about people's needs. There was a risk people would not receive appropriate care.

The system to ensure safe management of medicines was ineffective. The provider failed to identify that staff were not storing medicines in a safe way, medicines storage equipment was faulty, and people’s medicines records were inconsistent.

The provider failed to implement systems and processes to ensure incidents of alleged abuse were shared with the appropriate authorities and investigated. This placed people at risk of harm.

The provider failed to ensure oversight of recruitment records, gaps were identified in recruitment records during the inspection and senior staff confirmed no audits of recruitment records had been completed.

The service has had no registered manager in post since 1 May 2024. There was no evidence of provider oversight at the time of inspection. The managerial oversight that was in place was ineffective and this placed people at risk of harm.

In response to the concerns identified during this inspection the provider began to make immediate improvements to the service. These improvements now need to be sustained and embedded.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.