Rawreth Court

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 good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The provider was previously in breach of the legal regulation in relation to good governance. Improvements were found during this inspection, and the provider was subsequently no longer in breach of this regulation.

This service scored 71 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The registered manager had a clear idea of the type of care they wished their service to provide. They were extremely proud of their gold standards framework accreditation (GSF). Staff and the registered manager were all incredibly proud of this. A lot of work had also gone into ensuring that the home was a welcoming and homely environment, and there was a marked improvement from the last inspection we completed. The registered manager told us, “I have taken this challenge on, the last CQC report was a challenging read, however the team is very strong, and we have our team philosophy, we aim for all service users to enjoy their day.” Feedback received from people indicated that this had taken hold in the service and was experienced by those receiving care and their relatives.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Without exception people told us they felt the service was well run. Feedback we received included comments such as, “The home manager is very nice. Yes, she’s great. They’re just so accommodating.” “[Registered manager] lovely [person], absolutely approachable, any issues they deal with them.” “Manager spoke to me about [person] being end of life, after this a member of staff had come up to me and held my hand saying, ‘we are always here if you want to talk.’ It’s not just a job to them, they are brilliant, can’t praise them enough”

This was echoed amongst the staff team, one staff member in describing the registered manager told us, “[Registered manager] is great, they are amazing, they really helped me a lot. They are a really good manager, they know each staff weakness, strength and they support so much. They are a good person and can still correct me in a very firm way, they always try to teach me something without making me feel [bad]. I am really confident because of that one person.”

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

The provider had a policy in place to ensure staff were able to raise any concerns. Staff were aware of the policy and mostly described feeling comfortable to raise any concerns.People and their relatives felt that the management team were approachable and felt confident that concerns would be dealt with professionally. Staff also felt they could speak up and indicated this had improved under the new manager. A staff member told us, “I could go to the manager about any concerns, I would be heard.”

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.

Staff told us they felt valued, respected and treated fairly within the workplace. Most staff had completed equality and diversity training, demonstrating the provider's commitment to promoting an inclusive culture. This helped staff to understand and respect people's individual backgrounds, characteristics and experiences, supporting the delivery of person-centred care and helping to create a positive environment for both people using the service and staff.

We observed this in practice, and saw there were multiple roles within the service, including management, nurses, health care assistants, domestic staff and maintenance. We noted positive working relationships between all these roles. A staff member told us, “Since [registered manager] has been here the nurses will now help us out. All really nice here at the moment.” Another staff member told us, “We work as a team we have a good working relationship with the clinical team. We have built that up.”

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.

Governance and oversight arrangements were not always effective in identifying, monitoring and addressing risks to people's health, safety and well-being. We identified concerns relating to care planning, risk management, medicines management, record keeping and compliance with the Mental Capacity Act, which meant the provider could not always demonstrate that people consistently received safe, high-quality care.

The registered manager was open and transparent about the challenges facing the service. They told us that feedback from the inspection would be actioned and that an action plan was in place to address these.

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.

Relatives spoke positively about how the service worked with external professionals to support people's health and well-being. Effective partnership working helped to ensure people could access specialist advice and support when needed, contributing to positive outcomes.

People were also encouraged and supported to remain involved in their local community, including taking part in visits and outings to local places, as well as the service hosting fetes for the community. This helped people to maintain social connections, reduce the risk of isolation and support their overall well-being.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

A new electronic system for audits was being rolled out by the registered manager, which was to be used to conduct audits for a variety of care practices. For example, there was a ‘clear to care’ audit in place, this was completed twice a day at the start of each shift, this ensured vital checks were done before a handover between shifts was completed. This ensured that any outstanding actions or issues were either completed or handed over successfully.

During our inspection, we found the registered manager was extremely responsive to any feedback we gave them, acting immediately on suggestions or changes that were required. This included carrying out an internal investigation into medicines optimisation issues addressed above as well as implementing new daily manager checklists to better capture oversight in place.