Archived: Ravenhill Way

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

We identified 1 breach of the legal regulations in relation to governance. The provider and registered managers quality monitoring systems were not always effective. They had not identified the shortfalls we found during our assessment. Staff were not up to date with their mandatory training, and other training modules described in the provider’s policies. The registered manager had not ensured safe recruitment practices were being followed. Care records were not reflective of people’s current needs. Audits and checks had failed to identify the concerns we found during our assessment. People’s relatives spoke positively about the service and said it was well managed.

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 registered manager was clear about their roles and responsibilities. However, quality assurance systems in place had not always identified and addressed areas for improvement. The registered manager was unable to describe all the events and incidences they were required to report to CQC and other relevant agencies. Staff said the registered manager was supportive and knowledgeable. They also confirmed senior managers visit the service regularly. Staff said, “There is a teamwork approach at the service. The [registered manager] is approachable and fair to all staff and people living at the service.”

The providers governance system to monitor quality and safety of the service were not effective. The quality assurance systems included several audits. These included medicines, infection prevention and control (IPC) and care records. There were gaps in the system and these audits had failed to identify the concerns we found in relation to safeguarding, incidents and accidents, the environment, IPC, and care planning, including MCA’s. Overall, this meant the registered manager’s audits were not effective. Records were not always completed and accurate. Staff had not completed mandatory and specialist training to provide safe and effective care, and this was evident within training records. We also found concerns relating to safe staff recruitment with several pieces of information missing. Cleaning records were not accurate and did not reflect the environment we observed during our site visits. Policies and processes were in place. Including a policy to safeguard people from potential harm; however, these policies weren’t always followed. There were several policies that were outdated, including recruitment, induction and onboarding, supervision, and appraisal. The service confirmed all these policies are currently under review. Induction and supervision records had not been completed in full. There were elements of copying and pasting information from one month to the next within supervision records. An internal health and safety audit had not been completed by the registered manager, although the landlord had recently completed their own one. Following our assessment feedback senior managers confirmed the internal health and safety audit took place in May 2024. Senior managers also confirmed a new monitoring schedule had been implemented to include team meetings, meetings for people living at the service and supervisions.

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.