Banbury Heights Nursing 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 Good. At this assessment the rating has changed to Requires Improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance at the service.

This service scored 62 (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. Staff had a good understanding of the providers’ vision, strategy and culture. Staff told us the providers’ core values and demonstrated how these were put into practise every day by “promoting positivity and dignity”. Staff told us that they worked well together.

A person told us “I am being well looked after. I am happy here.” Relatives told us, “Staff are consistent and very kind and caring, they protect [person’s] dignity”.

Leaders at every level were visible. Some did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

We identified issues in systems and processes that the leadership team had failed to identify. The provider did not always ensure that managers had full oversight of the service, and at times leaders lacked some of the skills or knowledge needed to fully safeguard people from potential risks such as people receiving too much medication, inconsistencies in care plans and recording, and failure to identify and mitigate risks relating to fire safety, people with behaviours that communicate an emotion or distress, or choking risks. The provider was responsive and took action to investigate our concerns.

People and their relatives knew who the registered managers were. We observed the registered managers for the service to share kind, caring interactions on the day with residents.

People’s relatives told us “I have a lot of respect for the managers. They are both very approachable.” Staff told us, “The managers are good and approachable.”

The senior leadership team knew staff well and demonstrated compassion and inclusiveness. The provider had recruited a clinical governance lead to support with clinical oversight of policies and procedures.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. An in-date freedom to speak up policy was in place, posters were displayed throughout the service.

Staff told us they knew who they could speak to and how to raise concerns if required. Team meetings were held regularly, and staff were offered multiple opportunities to raise feedback. Complaints were investigated and resolved appropriately.

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.

Staff told us they were treated very well by the service and felt that leaders were supportive. We saw no evidence of discrimination.

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.

The provider’s processes to monitor the safety and quality of the service was not always effective. Systems and processes for medicines had failed to identify where people were being given too much medication or had not been given their medicines in a timely manner.

Systems and processes failed to identify people’s daily records were inconsistent in regard to recording people’s skin integrity and emotional wellbeing. Audits were not in place to monitor distressed behaviour, despite some people at the service displaying these behaviours and staff not always responding appropriately to this.

Systems in place failed to identify that risk assessments and care plans were not clear, complete or contemporaneous. Audits had not identified gaps in recording of catheter checks, and communication with professionals.The service was not following their own policies in relation to falls and infection prevention control. This meant there was poor oversight of the service and people were put at harm as a result.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

We observed records of activities provided by local community partners at the home. The provider told us about their links with a local sports team and trips out to local tea rooms.

However, relatives provided mixed feedback about people being able to access the local community. Comments included “They do take them out but recently they haven’t as they don’t have a minibus” and “They do trips out and they have people from the community that come into the home.”

The provider focused on innovation and generally reviewed improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

Staff told us they felt supported and listened to. The provider had an online forum where leaders could give recognition to staff for their work. This forum was used to improve innovation and learning at the service.

We observed records of resident committee meetings that had taken place at the home. We saw evidence of staff, people and families feedback surveys. The provider had taken some action to address issues such as improving the frequency of activities.

Families told us they attended meetings at the service and felt able to speak up and contribute to decisions made about the service. Comments included “They have a relative meeting every few months and you can raise anything then” and “You can go to meetings, and they give explanations on what’s going on.”

The provider did not always identify lessons learned from incidents in the home, and care plans did not always reflect incidents of distress. This meant people were at risk of repeated harm.