Ridgemount

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

The provider had a schedule of quality assurance systems in place to support them to be able to review and assess the service delivery. However, whilst people received safe care, these audits were not always effective in identifying some areas of improvement identified by inspectors on the day of assessment. Following this assessment, the provider submitted supporting documentation to evidence improvements made since the assessment day. The culture of the home was open, honest and transparent, with people and staff treated fairly and their diversities respected. Feedback from staff about the leadership team was predominately positive. They told us the management team was supportive and encouraged staff to speak up and raise concerns without fear of discrimination. They gave staff, people and relatives the opportunities to provide feedback and to freely access the registered manager and other senior members of staff. Leadership was sustained through safe and effective recruitment.

This service scored 61 (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 was on annual leave during this assessment process. We engaged with the deputy manager and district manager and any concerns we raised were either acted upon immediately or rectified during the assessment period. People who used the service gave feedback about how the senior leadership team engaged with them. They told us, “Yes, they’re alright, they put me straight, they’re very good to me.” Family members said, “Any problems, they are straight on the phone. Any incidents and they tell us straightaway.” Feedback from staff on the leadership team was generally positive. They told us they had regular staff meetings and felt included in the day to day life of Ridgemount. One told us, “They’re good, they’re approachable. When I see them they say hello. They come out on the floor to say hello every day. They always say hello to the residents,” and “They are good, I can speak to them.” Others said, “The management are quite supportive. The registered manager is down to earth, you can always talk to them. If someone is not happy, [registered manager] knows and she will call them in to find out what’s happening. They have made everyone work as a team.” Staff told us they felt confident to raise matters of concern with members of the senior leadership team and knew how to escalate if they felt they were not listened to. One told us, “I know I can whistle blow to the whistleblowing team or I’d speak to head office.” We observed as we went around the home how service users addressed the management team in a confident and relaxed way. It was evident to inspectors there was an established and trusting relationship with senior staff, as well as those who directly supported them.

Members of the leadership team were aware of how different members of staff may require support in different ways. They appeared engaged, relaxed and confident with people living at the home. Leadership was sustained through safe and effective recruitment. During the assessment, any concerns we raised to the leadership team were acted upon immediately and rectified during the assessment.

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.

Staff members did not express any concerns in relation to equality, diversity, and inclusion. Staff told us they were treated fairly and respected by the management team. They also told us they completed equality, diversity and inclusion training each year. The district manager gave examples of how they ensured diversity was valued and staff’s individual choices were respected.

The provider had policies in place to ensure equality and inclusion across the workforce and the Equality Act 2010 was embedded in their equality and diversity policy. Systems were in place for staff to report any discriminatory behaviours which they may be concerned about.

There was a management structure in place which staff understood and which supported them in fulfilling their own roles and responsibilities. The registered manager was on annual leave at the time of assessment, and in their absence, the deputy manager and district manager continued with the day to day operation of the home. They also fully engaged with the inspectors to support the assessment. Staff told us, “We have handover meetings so if something has happened in the night they will tell us so we’re aware,” and “There are regular staff meetings and staff will say what they want to say to management. Anchor also does annual staff surveys.” Feedback from healthcare professionals included, “Communication between us and the service is transparent and timely”, and “Management are approachable and any problems are discussed at the time.”

The provider conducted monthly audits across different areas of the service. Quality assurance systems were in place and quality checks in areas such as infection control, medication, falls, health and safety and food quality were completed regularly. However, whilst provider audits identified areas for improvement and which were identified by inspectors, these were not in place by the time of this assessment. For example, inspectors identified conflicting guidance in care records; inconsistent recording of episodes of care; lack of clarity as to when staff medicine competency assessments were completed and staff supervision records not available for inspectors to review on the assessment day. The provider compliance audit completed in June 2024 identified similar areas for improvement and noted, ‘care plans are being updated in a timely manner and contain conflicting information which is neither person centred or reflective of current support needs; advanced competency observation seen to be at 22% compliance which will require improvement as soon as possible; supervision tracker is currently being reviewed and updated; on review and in discussion with the registered manager, some colleagues currently have their most recent supervision session outstanding.’ These shortcomings were acknowledged by the area manager and the deputy manager during feedback at the end of the assessment day. Since then, measures were put in place to mitigate potential risk and to address these issues. The provider initiated an action plan and shared supporting evidence which demonstrated the majority of these shortcomings were addressed in the days following the on-site assessment, with target completion dates for remainder within 4 weeks post-assessment. Statutory notifications (events that the provider is required to notify CQC of) were submitted in a timely way and the provider's business continuity plan was detailed in its preparedness for unforeseen emergencies.

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.