The RedHouse 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

We assessed 3 quality statements in the well led key question and found areas of concern. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. Though the assessment of these areas indicated areas of concern since the last inspection, our rating for the key question remains good. The provider’s governance systems were not always effective in driving improvement and did not identify all of the shortfalls we found during this assessment. Concerns were found with regards to records for medicines, care plans, risk assessments, cleaning schedules, accidents and incidents, mental capacity assessments and best interests. This has resulted in a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below. In response to concerns raised during the assessment, the provider was responsive in taking prompt action to address shortfalls. The registered manager told us they had worked hard with the staff team to cultivate a positive culture and that most of staff had embraced this and adapted their practices and approaches in response. The registered manager told us it was important to them to be visible and accessible to people and ensured they spent time out of their office every day. People, relatives and staff knew who the registered manager was and were able to spend time with them as they wanted and needed to. Professionals spoke highly of the management team who they said were knowledgeable about people and engaged well with them which helped ensure people’s needs were met. One professional told us, “It is a very well led service… [Registered Manager's name] is very people orientated, she always works extremely hard, always in the home even when she should be on leave. Very approachable very open to new ideas and has an open-door policy."

This service scored 75 (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.

The registered manager knew people; they were able to discuss in detail people’s needs, likes, dislikes and preferences. They were aware of positive outcomes for people and what people were working towards. The registered manager told us they had an ‘open door’ policy and we observed this in practice. People, relatives and staff knew who the registered manager was and were able to spend time with them as they wanted and needed to. The registered manager told us it was important to them to be visible and accessible to people and ensured they spent time out of their office every day. The registered manager was passionate about person centred care and ensuring the values of the service were embraced and demonstrated by staff. They told us how they provided direct support to people to role model the values and best practice. The registered manager told us it was important to them to be able to understand each staff member’s role to ensure they supported them effectively. They told us they spent time carrying out the different roles in the home working alongside staff. This enabled them to role model best practice, understand the challenges facing staff and for staff to get to know the registered manager and be comfortable sharing ideas and concerns. The majority of feedback from staff was very positive about the registered manager and management team. Comments included, “[Registered manager’s name] is really nice and approachable”, “[Registered manager’s name] is approachable, listens to suggestions” and “Registered manager’s name] is most probably the most hands on manager I’ve worked with. [Registered manager’s name] comes out on the floor, makes sure we are ok, if we need any help.” The registered manager told us about the challenges they had faced when they first started to manage the service and how they had worked with staff to cultivate a positive culture which the majority of staff had embraced and adapted their practices and approaches.

The provider had effective contingency plans in place. There were systems and processes in place to support staff development and progression within their roles. The provider’s senior management visited the home regularly and provided support and supervision to the registered manager. The registered manager attended regular manager meetings which enabled learning across the organisation to be shared and relevant lessons learnt implemented within the home. Regular supervisions, spot checks, competencies and values based supervisions took place. The provider supported the registered manager and staff to attend external training, conferences and meet with other providers and managers to network through various forums. To support the open and positive culture. The registered manager was open that this was a work in progress and that supervisions, team meetings, role modelling and values-based recruitment was key in supporting this culture change. They had processes in place to evidence this.

The registered manager was able to detail how they promoted a culture of openness and transparency. They told us they had an ‘open door’ policy and we saw this in practice. The registered manager was open about lessons learnt and what they had implemented to prevent recurrence. They understood duty of candour and their responsibilities. Staff were able to describe and demonstrate their knowledge in relation to whistleblowing and were familiar with how to raise concerns within the organisation, and externally, if necessary. The majority of staff we received feedback from confirmed information was shared, including lessons learnt, and they were able to feedback suggestions and ideas for improvements and felt listened to.

The provider had up-to-date whistleblowing policies and procedures which were in line with current guidance. There was a suggestions box available to people and staff for feedback to be shared. People, relatives and staff had opportunities to feedback about the home in formal and informal ways. The provider had a complaints procedure in place. There were clear roles and responsibilities for all staff and there were processes in place to ensure staff had access to other senior leaders if they had concerns they weren’t comfortable raising to the registered manager.

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 majority of staff were confident in the leadership team and that they were committed to delivering a good quality service. Staff confirmed they were encouraged to share ideas and be involved in improving the service. Staff told us they found team meetings useful to discuss learning and explore ideas and suggestions. The registered manager told us they involved staff in different roles in completing audits with regular changes to minimise the risk of complacency and things being missed. They told us whenever an audit was completed they had oversight to ensure consistency and actions were completed. The provider told us they were always looking to improve and revise their governance processes to ensure they were robust and effective. However, they recognised improvements were needed in some areas as learning from other areas of the organisation had not always been effectively implemented and they had not picked this up through their current processes. Professionals spoke highly of the management team who they said were knowledgeable about people and engaged well with them which helped to ensure people’s needs were met. Comments included, “It is a very well led service… [Manager] is very people orientated, she always works extremely hard, always in the home even when she should be on leave. Very approachable very open to new ideas and has an open-door policy and “She really engages with the residents and is always busy doing something, always present and walking around in the home.” Professionals working within the service told us the leadership team were proactive and took action to ensure that enhancements such as a varied activities programme was delivered. For example, 1 professional said, “The manager is lovely and is very proactive and gets excited about any form of entertainment for the residents. [They are a] really great presence in the service”.

There were some governance systems in place. However, they had not always been effective at identifying the areas of concern identified during this assessment. Effective systems had not been established to ensure accurate and complete records were maintained. There were shortfalls in records viewed relating to cleaning schedules, medicines recording, recruitment, accidents and incidents, care planning, mental capacity assessments and best interests. The provider took action in response to the concerns identified to address the shortfalls. For example, they implemented more robust recruitment forms, sourced additional Mental Capacity Act 2005 training, reviewed the mental capacity and best interest records for people and implemented a new electronic care planning system. They needed time for these actions to become embedded within the service. The provider had regular quality assurance audits in place which included regular audits by their compliance team who were not based at the service. This enabled the provider to have oversight over the service and support the registered manager in making improvements. The leadership team engaged with local partners to ensure that they were kept up to date on best practice. One health care professional said, “[The registered manager] has always been very proactive in asking for support when needed in a timely manner. They attend our area managers meetings and often send staff to our training. This professional told us that their colleagues were also positive about the service and had reported no concerns.

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.