Ryhope Manor 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

Whilst people and most relatives spoke positively about the registered manager; the findings identified at this assessment did not evidence that leaders had the capacity and capability to ensure high quality care was delivered and risks were well managed. We identified shortfalls in many areas of the service. The registered manager explained that their management duties had been affected because of additional training they had delivered to new staff and having to carry out care duties. They spoke very positively about their dedication to the people who lived at the home. An effective quality monitoring system was not in place to ensure regulatory requirements were met. We identified shortfalls across the service which had not been identified by the provider's quality monitoring system. Whilst the registered manager carried out audits and checks; there was no evidence of provider oversight. These issues constituted a breach of Regulation 17 (Good governance). CQC had not been informed of all notifiable events at the home. This was not in line with legal requirements. This failure exposed people to the risk of harm since there had been no overview by CQC to check whether the appropriate action had been taken.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

An effective strategy was not in place to develop a shared direction, culture and vision to ensure high quality care was provided. A system to involve people and relatives in the running of the home was not in place. The registered manager told us they spoke with people and relatives on a regular basis to find out if they were happy or had any concerns. This information was not documented, analysed or used to evidence any improvements or actions taken. During our assessment, whilst management staff took action to address some of the issues identified and formulated an action plan to address the outstanding areas; this action had only been prompted by our feedback.

Whilst people and most relatives spoke positively about the registered manager; the findings identified at this assessment did not evidence that leaders had the capacity and capability to ensure high quality care was delivered and risks were well managed. We identified shortfalls across most areas of the service. The registered manager explained that their management duties had been affected because of additional training they had delivered to new staff and having to carry out care duties. They spoke very positively about their dedication to the people who lived at the home. Following our feedback, management staff took action to address some of the issues identified and formulated an action plan to address the outstanding areas.

There were processes in place to encourage staff to share concerns and speak up. Staff told us the registered manager was approachable and supportive. Staff were confident any concerns they raised would be acted upon.

We received concerns regarding the equality and diversity of the recruitment process. The home’s recruitment policy did not reflect the recruitment practices in place. Staff told us they enjoyed working at the home and felt supported. Staff meetings were carried out to involve them in the running of the home.

An effective quality monitoring system was not in place to ensure regulatory requirements were met. Whilst the registered manager carried out audits and checks; these had not identified the shortfalls we had identified or ensured timely action was taken to address the issues. In addition, the provider did not complete any documented checks to evidence provider oversight. CQC had not been informed of all notifiable events at the home. This was not in line with legal requirements. This failure exposed people to the risk of harm since there had been no overview by CQC to check whether the appropriate action had been taken. Following our feedback, management staff took action to address some of the issues identified and formulated an action plan to address the outstanding areas.

External agencies told us there had been recurring shortfalls in relation to infection control and fire safety. This meant that improvements which had been advised by these agencies had not been sustained. The local authority told us the service were working with them to implement the improvements required. People told us they were supported to access health and social care services. We received mixed feedback from health and social care professionals; one professional told us that their advice was not always followed; another spoke positively about the care which was provided.

An effective system was not in place to identify and share lessons learned. There was no evidence that accidents and incidents, complaints and safeguarding allegations were reviewed and monitored to identify any trends or themes and lessons learned so action could be taken to minimise the risk of any reoccurrence. Following our feedback, management staff took action to address some of the issues identified and formulated an action plan to address the outstanding areas.