Haven 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 care.

The service was in breach of legal regulation in relation to 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.

The registered manager encouraged an open culture focused on providing people with person centred care. They explained, “Safety is a main priority, but it is about respecting people’s wishes and promoting their independence as much as we can. It is about making it as enjoyable as we possibly can and respecting them as an individual."

Conversations with staff demonstrated they understood the values promoted by the registered manager. One staff member told us, "They want the care to be right and to have a good running home with the right values and to make sure everyone is happy." A member of the management team told us they regularly observed staff to ensure they reflected the values in their everyday practice. They commented, “I want to achieve the best place you could possibly put your relative and know they are cared for. I walk around the home and not only am I watching the care, but I am building a relationship with people and families and listening to what is going on out there."

Staff told us they enjoyed working at Haven Nursing Home and described an environment where managers and staff worked together to ensure people’s needs were met. Comments included: “Teamwork is the name of the game. There is no us and them. It is one team, like a big family”, “This is a good place to work. It’s more than a home; it’s a family” and “I’ve worked in other homes where it was them [management] and us (staff). Not here, we all work tightly as one for the residents.”

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.

Staff told us they felt very supported by the registered manager and deputy manager because they were knowledgeable, approachable and available to discuss any concerns. Comments included: “Our manager always finds time to talk to you. No matter if it is something small or big. The deputy is a real team player” and “The manager and the deputy are brilliant. In all the years I have worked in care I can say in all honesty they are the best managers I have ever had.”

Staff described ‘hands on’ leadership with managers working alongside them when guidance or support was needed. One staff member said, “I don’t think we could ask for a better management team. They are out on the floor not just stuck in the office. If you need help, they are there. It makes us (staff) feel like we really are a team.”

The registered manager told us the provider was very responsive when they needed extra support or any equipment for the home. They told us they had regular meetings with the provider’s operational team who were supportive of their leadership in the home.

People, relatives and other health and social care professionals did not raise any concerns about how the service was run.

There was a positive culture where people felt they could speak up and their voice would be heard.

Despite limited available information about how they could formally ‘speak up’, staff were confident to share any concerns with the management team. One staff member told us, “Hand on heart if you want to say something good or bad you can. At the staff meeting we all speak up. The manager wants you to share your ideas and to be honest about how things are.” Another staff member commented, “Things are open here. If you have a thought or a view you can say it. Everyone may not agree but you can say what’s on your mind.”

The registered manager told us they encouraged people to speak up by ensuring they received feedback and understood they had been listened to. They explained, “If staff feel they are wasting their time and nothing is going to change, then they won’t tell me. Sometimes I can’t disclose the whole picture, but I make sure they understand it has been acted on and taken seriously."

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 service celebrated a diverse range of people and staff. The provider had an equal opportunity and a bullying, harassment and victimisation policy which were shared with staff in the employee handbook.

Staff told us the registered manager promoted an inclusive environment where they were treated fairly. One staff member told us, “The way my manager has supported me and changed things around to help me makes me feel very valued.”

The provider did not have clear responsibilities, roles, systems of accountability and good governance. The provider did not always ensure information was managed in line with current legislation and guidance.

The provider had a video surveillance system (CCTV) in communal areas of the home. CCTV in care homes is permissible under specific legal and ethical guidelines.Care providers must prioritise people’s privacy, obtain consent, and justify the use of surveillance, ensuring it is necessary, proportionate, and transparent.A Data Protection Impact Assessment(DPIA) considers the need for the CCTV system and should be carried out before a CCTV system is installed and regularly reviewed. A DPIA is a legal requirement under UK date protection legislation when processing personal data likely to result in a high risk to the rights and freedoms of people.The provider had not completed a DPIA in line with legal requirements. The provider completed a DPIA following our inspection, but it lacked detail and did not cover all the legislative requirements. There was no policy to support the use of CCTV and required consents had not been obtained. Associated policies had not been updated and reviewed to reflect use of CCTV in the home.

Care providers in England are legally required to display their currentCare Quality Commission (CQC) rating prominently and clearly at their premises and on their website. On the first day of our inspection the provider had failed to display their rating as required. We were informed this was following a period of refurbishment and action was immediately taken to ensure the current rating was displayed in line with regulatory requirements.

The provider’s audits and checks had not identified the issues we identified during our inspection visit. For example, a lack of an effective system to manage Deprivation of Liberty Safeguards and no service level analysis of accidents and incidents. Some audits were not sufficiently detailed to ensure a robust system of checks. For example, in relation to infection control and fire safety. Some policies and procedures did not support the effective governance of the home. The provider’s processes to quality assure the service needed to be improved to identify areas for development and compliance with legislative requirements.

Oversight of clinical care and medicines management by the registered manager was effective and ensured standards in these areas had been met.

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.

The registered manager worked with other organisations to ensure people received a consistent service. This included those who commissioned the service and other professionals involved in people's care. The registered manager had also developed close links with local organisations that enhanced and benefited people's lives and allowed them to remain active members of the community. For example, people were able to attend local football matches through partnership working with 1 organisation and another organisation regularly supplied coffee and cakes to the home. Other health and social care professionals were positive about the benefits to people from effective partnership working.

One external healthcare professional told us, “We've worked with Haven Nursing Home for many years. They really do go above and beyond to offer the best for their patients.I have no concerns about the care they've offered.”

The provider did not always focus on learning and innovation to ensure information in all formats was managed in line with current legislation and guidance.

The provider had introduced a CCTV system into the home without a comprehensive appraisal to ensure compliance with relevant legislation and guidance. This included the Mental Capacity Act 2005, Human Rights Act 1998 and the General Data Protection Regulation.

The registered manager was focused on continuous learning and improvement across the service. They acknowledged our feedback and took immediate action to address issues identified in relation to the oversight of accidents and incidents, safeguarding referrals, Deprivation of Liberty Safeguards and directional signage in the home. They demonstrated a positive attitude to learning from feedback to improve the quality-of-service provision.

Staff told us they were encouraged to develop in their role and gain further qualifications to improve their practice. One staff member told us, “Training here is second nature. If you see a T by your name, you know you’re on a course. I think it’s good the management want you to keep learning. It (training) is beneficial as things do change, and it keeps you up to date.” Another staff member commented, “We all work together and want to get things as good as they can be, so we are all willing to change.”

The provider had achieved an Investors in People gold award in recognition of their commitment to invest in the development of their staff.