Rakewood 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 requires improvement. At this assessment the rating has changed to good.

The service was previously in breach of legal regulation in relation to Good Governance. The provider had failed to assess, monitor and improve the quality and safety of the service, and to ensure there was an accurate, complete and contemporaneous record in respect of each person supported. At this inspection the provider is no longer in breach of this regulation. 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 75 (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 home was calm and relaxed during the 2 days on site assessment. There was a consistent staff team in place with a shared vision to provide person centred care responsive to people’s needs which was strongly driven by the registered manager. The staff we spoke to were able to explain the goals of the service, one carer said the aim is to “provide quality care and we all try to do that, including the management”.

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.

The feedback we received about the management team was very positive. One staff member said, “The seniors are wonderful” and we observed the registered manager regularly walking around the unit, speaking to staff and residents. The registered manager told us she works alongside the staff who said that she is very supportive and visible.

One relative said “[Registered manager] is lovely and very approachable. At first she sat us down and explained what would be happening and what they would do for him and asked all about him. She seems a very committed person”.

The registered manager shared with us how she ensured an elderly resident’s food was cooked correctly by asking a staff member from the same background who was confident in cooking this food, to teach the kitchen staff how to make it.

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

Staff received the whistleblowing policy and explained there is a phone number in the staff room which provides the opportunity for staff to speak up. A member of staff told us that a member of the human resources team come to the unit providing further opportunities for staff to raise concerns.

The staff said the manager had made positive changes and they felt anything they raised would be taken seriously and acted on appropriately. There was an open and transparent culture within the service which the manager actively encouraged, and regular supervisions provided further opportunity for staff to talk openly.

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.

The staff team came from a range of backgrounds and said they felt they were all treated equally. The registered manager promoted putting people first and respecting each other.

We observed a staff member, who could speak the same language as a person, support them during a mealtime. Staff were seen encouraging the person to eat by communicating in their first language. Staff’s individual strengths were recognised.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The registered manager was aware of their legal responsibilities and notified the CQC and local authorities of any events affecting the health and well-being of people living at Rakewood House.

Regular audits were in place to provide oversight of all areas of the service and a ‘resident of the day’ initiative ensured regular detailed reviews of the care of each resident including conversations with the families. There was a learning culture, and actions were identified for any shortfalls found.

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.

There were strong and effective relationships in place with local health and social care professionals to support good care. The registered manager and staff said the local GP practice was available and responsive, sending a GP over the same day if required. We observed the optician and a member of the Speech and Language Therapy team (SALT) onsite while we were there. The local hospice had also provided recent training on the palliative passport.

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.

The minutes from regular staff meetings clearly outlined the areas where improvement was needed and the actions that needed to be taken. While the majority of these were being actioned, there is some development needed in the activities offered to people to ensure meaningful activity and the best quality of life is being promoted.

A relative told us “I found that if they were doing hygiene with her near dinnertime, she would get distressed. I went to [registered manager] and ask if this could be done earlier if possible depending on what state she was in. [Registered manager] told all the staff and sorted it out”.

The registered manager constantly looked to improve the service and regularly asked for feedback from the staff. The provider had provided the funding for some members of staff to complete the NVQ Level 3 at the registered manager's request.