Susan Hampshire House

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. 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.

There was a positive atmosphere and culture in the service where people were treated with respect and supported to live the life they wanted. The registered manager told us in their provider return ‘everyone who lives at Susan Hampshire House has the right to be treated fairly, with respect and free from discrimination. It is important we support individuals in a person-centred way to ensure their views and wishes are always at the heart of any decisions made about them.’ Staff were observed promoting these values during our visit to the service.

A member of staff told us, “Management go above and beyond to help out and take care of all of our residents and I can ask anything, and they know how to answer it and they know the correct way to do things which I didn’t have in a previous home”.

Relatives told us staff had the right skills to support their loved ones. This included when people’s needs changed, such as going through a diagnosis of dementia. A relative told us, “The staff show real empathy and caring in their approach”. All relatives we spoke with praised the registered manager and the deputy manager in keeping them informed of any changes. Visiting professionals praised the manager and the deputy in changing the culture of the service with a more person-centred approach now being in place rather than being task orientated.

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 registered manager had been working in the service for the last 12 months. They had made improvements to the service including the culture and how the team supported each other and the people living in Susan Hampshire House. Relatives, staff and professionals spoke positively about the changes. A relative told us, “I am very pleased with the new manager, after many years of that not being the case. (Name of Manager) is doing an outstanding job”.

The management team were visible, knowledgeable and supportive. Both the registered manager and the deputy manager worked alongside staff to help them develop in their roles and support people living in Susan Hampshire House. The provider regularly visited the service to meet with people, staff and complete checks on the home to ensure ongoing compliance. An area manager was a frequent visitor the service supporting the registered manager and the staff team, alongside their responsibility to complete checks on compliance.

The registered manager attended monthly management meetings where learning and risks were discussed across the whole organisation.

The registered manager had won an aware for care manager of the year for the positive impact they had in managing and supporting staff and creating an open-door policy for people living in the service and the staff.

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

Relatives told us they felt comfortable raising concerns without fear of recrimination. Staff said they were encouraged to speak up if they had concerns or ideas for improvements and said their feedback was listened to. Staff confirmed there had been improvements such as receiving regular supervisions and now team meetings were happening on a regular basis.

People’s views were sought through care reviews, surveys and an easy read survey which included happy or sad faces to enable people to express how they are feeling and to highlight what is working well or not working well for individuals or anyone who visits the service. Resident meetings were also a forum where people could raise concerns or make suggestions for improvements.

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 registered manager told us, they used an active support model which embeds human rights principles ensuring every individual is treated with respect, fairness, equality, dignity and autonomy. Staff told us they were proud and enjoyed working at Susan Hampshire House.

Policies were in place to protect and promote the rights of the people using the service and the staff team. Staff had completed equality and diversity training.

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.

Since the last assessment improvements had been implemented to ensure the provider’s governance arrangements were robust. The service was no longer in breach of regulation.

The provider now had a robust system in place to check the quality of care. Audits were completed on a regular basis covering all aspects of care delivery. There was a service improvement plan in place. This was monitored by the registered manager and signed off by the area manager. Where areas for improvement were identified, action was taken to address them.

The registered manager understood their regulatory responsibilities and information and legally required notifications were shared with external organisations as required.

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.

Since the last assessment improvements had been embedded which included working closely with health and social care professionals and building on relationships. Feedback from professionals was positive including how the management team and staff communicated with them. Comments included, “Much improved service since the X has become the manager. Historically there was definitely a split staff team, but I think this has improved. Communication has improved between the service and the local authority.” Another health professional told us, “They know their residents very well and the care I have seen has been first class. The staff are responsive to the resident's needs and person centred.”

People were encouraged to maintain relationships with those who were important to them and engage in activities, which were meaningful and improved their quality of life. People confirmed they were supported to go out within their local community. People were supported to go to the local shops or for walks around the local area. People were supported to attend the local church on a Sunday enabling them to be part of their local community.

The provider engaged in local forums and worked with other organisations to improve care and support for people using the service.

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.

There was evidence of positive changes that had been made to the service since our last assessment. The provider had a service improvement plan which included all actions that were either achieved or planned. The management team were passionate about making improvements to the service putting people at the heart of those improvements ensuring care was person centred and led by the individuals. The registered manager was aware that improvements were needed in relation to the assessments of people’s skin integrity and was planning to liaise with the GP and district nurses.

The registered manager had recently held an arts and crafts session which focussed on supporting people to make decisions about end-of-life plans. This had been creative in helping people express their wishes on a topic that may not be easy to express.