Redroof House Supported Living

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 service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

We have identified a breach of legal regulation in relation to good governance. The provider had failed to ensure governance systems were established and operating effectively and they had not identified the shortfalls found during this inspection.

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 service did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The purpose and shared direction of the service had not been fully considered. This meant the management team and staff were not always sure or equipped to move the service forward. The lack of effective quality assurances processes, robust policies and outdated knowledge meant there was a risk of instability within the service.

We raised this with the registered manager who understood the need to provide actions for the service that the staff team could implement and be measured against.

Staff told us that the service culture was one of a family home and this was shared by the service leadership. A member of staff told us, “Everyone cares for the residents, respects their dignity and interests. We care about small matters. It's like a family. The residents are like our family members; we care for each other.” Having clearer service aims would imbed and recognise this vision.

Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills or knowledge, experience to provide the oversight to lead effectively. Leaders did not always understand the context in which the service delivered care and support.

The provider and registered manager did not remain informed of regulatory requirements to ensure robust service oversight. They did not have a system established and embedded which demonstrated continual personal development to understand their responsibilities.

However, we did receive positive feedback from staff about the kind and compassionate approach of the management team. A member of staff told us, “The registered manager really cares about them [the residents] and the wellbeing of staff.” A social care professional told us, “The registered manager provides compassionate leadership, supported by leaders.”

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us there were forums for them to speak up in, such as team meetings and supervisions, and they were confident to do so. Staff told they had been provided with a contact list of who to contact outside of the service, if they had concerns that weren’t being listened to.

Relatives raised no concerns about not being listened to and staff told us they worked well with relatives.

People had support from an advocacy service. A social care professional told us, “The service had positively involved an advocate, when I was working with them.”

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

We observed a friendly, respectful and inclusive culture amongst staff at the service, with staff members coming from different backgrounds and ethnicities. Staff told us they were treated fairly. Many staff had worked at the service for a number of years.

The service 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.

Governance systems were not operating effectively as they had not identified the shortfalls found within this assessment.

Audits were not completed for people’s care, support and the safe operation of the service, meaning there was limited oversight of how to improve outcomes for people. This meant that sometimes it was not clearly identified where information could be found. There was inconsistency in how staff approached people’s care and support plans.

Although staff told us the registered manager observed practice there was no system to provide feedback or measure staff competencies. This meant the was a risk staff were not providing consistent care and support to people.

Quality assurance arrangements were not applied consistently and were ineffective. For example, policies and procedures were not always personalised to the service or followed.

During the assessment the provider and registered manager were fully engaged and committed to the improvements needed to ensure people were safe and the service was managed.

The provider understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborate for improvement.

Managers and staff shared information and worked with a wide range of professionals and services. A social care professional told us, “Partnership working between Redroof and myself has always been positive. I have been able to have open communication and discussion, [with the service].” Referrals had been made to a number of health and social care partners and there was evidence of involvement and action resulting from them.

People had been active in their communities. For example, the person who was involved in their local church and nationality community.

Staff were active participants of their community. Relatives told us that referrals to professionals had been made as appropriate and we saw documentation of referrals made by the service.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider and registered manager did not always have oversight of the service. There were not well-developed systems and structures in place to continually learn. Feedback had been sought from people, their relatives and staff, but there was a lack of evidence that this was acted upon in terms of improvements in the care that people received.

Although, there were accurate records of incidents and during handovers, there were no systems in place to take this information and learn lessons. This meant that action was not always taken to change practice that would improve outcomes for people and staff. It also meant that staff were not always included in learning lessons, meaning useful information and experiences was lost from the process. One member of staff told us, “We are ready to support the managers to improve things.” We raised this with the management team during the assessment, and they informed us about proposed improvements.

The management team acknowledged our findings and said they would be strengthening governance arrangements and introducing systems to support learning and improvement.