Riseley House 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 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.

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. Processes were in place to ensure there was a shared direction between the provider, staff and people who used the service. This was evidenced through meeting minutes and improvement plans. Staff reported a significant improvement in morale and acknowledged the progress made over the past 12 months, particularly with the stability and support provided by the management team.

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. People, relatives and staff provided positive feedback about the leaders. At the time of the assessment, the manager was in the process of applying to be the registered manager with CQC.

Leaders were aware of the main issues within the home since the last inspection and had worked hard, with collaboration from external professionals to drive improvements and work towards an action plan. This included completing an action plan set out from the local authority.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Systems were in place to ensure people were supported to speak up. Staff felt able to raise concerns with managers and felt they were listened to. One staff member told us, “The managers are really approachable and understanding. I would feel able to go to them with any concerns and would be confident they would take action.”

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. For example, an ‘employee of the month’ scheme was in place to show recognition to staff members. The manager shared examples of how support and adjustments were made to accommodate staff members’ personal situations and promote their wellbeing.

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 systems in place required some improvements, for example, daily audits that failed to identify prescribed creams stored in incorrect bedrooms. Additionally, some audits did not effectively identify some of the concerns we found on site, for example, an IPC audit completed by the manager failed to identify malodorous furniture. The provider took immediate action to improve the audits whilst we were on site.

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. The provider, with support of the activity coordinator, had developed strong community links to improve people’s access to local resources. One relative told us, “I have seen lots of changes over the past few months the main one being the activities, my loved one loves the singer that attends weekly.”

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. Since the last inspection, the provider had made significant improvements, demonstrating a clear commitment to continuous learning. An ongoing action plan was in place to drive further progress. Over the last 12 months, the provider sought support from external professionals to address concerns and implement positive changes. Additionally, the manager shared examples where staff members had been encouraged to develop and successfully progress into their current roles.