Te Hira Care Home Limited

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 inspection we rated this key question Good. At this inspection 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 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 aimed to have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion and engagement. They understood the challenges and the needs of people.

The provider and operations manager encouraged an open culture focused on providing people with person centred care. One staff member told us, “We have always been big on providing person centred care in the safest way possible, we have always been about the person.”

The provider aimed to ensure there were effective structured processes in place to monitor and review progress against planned goals. However, these had not always been effective. For example, staff told us they had not had regular supervision meetings to review their performance and role. This meant staff may not always have individual opportunities for their performance to be discussed and reviewed. One staff member told us, “I have never had supervision, but we do have meetings. I always try to attend.” They went on to say they felt they could speak out and say what was on their mind at the staff meetings.

We saw staff felt at ease to work with the management team demonstrating an open culture. One staff member said, "We all work together management included. Management are very hands on. We are a team in its truest sense.”

Staff understood equality, diversity, and human rights and demonstrated compassion and respect in daily practice. Staff were able to explain people’s needs and the support they required to ensure these were met.

The provider had inclusive leaders 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 and experience to lead effectively. They did so with integrity, openness and honesty.

At the time of our visit the registered manager was not available at the home, so the operations manager supported the inspection process with the provider. People felt the service was managed to their satisfaction. One person told us, “I am pretty satisfied really.” The person spoke positively about the staff and management team who they knew by name. The person added, “Its peaceful and everyone gets on.”

Staff spoke positively of their managers and said they were visible and gave them support and guidance when needed. One staff member told us, “I could talk to the manager if I had a problem or wanted some help.” Another said, “On a day-to-day basis if you need a manager they are there to help and they are always on call. One of the managers is based downstairs in the reception so they are about.”

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

People told us they felt able to approach staff if they had any concerns.

Staff understood their responsibility to be open and honest if something went wrong. Staff told us they were encouraged to approach the management team at any time if they needed to speak up about something. They felt confident they would be listened to. One staff member said. “Yes, I would say we can speak out. Staff do speak up in meetings or on a day-to-day basis if they need to.”

The provider told us they had a “Please Ask” policy that encouraged people and staff to “ask before telling.” This was to help ensure their voices and preferences were heard and decisions could be made involving them.

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 felt included in decisions about the service. There were staff from different backgrounds and cultures working at the home.

The operations manager was able to provide an example of how they had supported a staff member by making adjustments to their working shifts when they had needed to take time off for appointments. They told us, “We had structured meetings with them,” and as a result supported the staff member with their wishes to reduce their hours.

Another staff member was supported with a varied training schedule to support their learning style. The operations manager said, “We started training them and made sure we could tick off they had all the right training.” We saw that the provider had introduced various training methods to support staff needs with some being online and others being face to face.

Staff had access to the provider’s policies in relation to equality and diversity in the workplace, so they understood the provider’s expectations. One staff member told us, “I think it is inclusive here. We are all involved and you can have your say.”

The provider did not have clear systems of accountability and 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 did not have effective systems to identify, monitor and address risks relating to the quality and safety of the service. The provider's auditing and quality assurance processes had not identified a number of issues we found during the inspection. This meant there were risks to people not being identified or mitigated, placing people at potential risk of harm.

The provider had failed to identify risks associated with the environment. We identified environmental risks that had not been formally assessed, including issues relating to windows, hot radiators, furniture and ceiling openings. Risk assessments had not been completed in relation to windows not having restrictors, hot radiators not having protection and wardrobes in people’s rooms not being secured. There was no risk assessment in relation to a hole in the ceiling of the downstairs corridor. The provider explained that some ceiling openings had been left following repeated repairs to a water leak to allow the effectiveness of the repairs to be monitored. The provider said, “I didn’t consider the fire safety risk.” This hole was filled in during our inspection visit along with further holes in the ceiling of the boiler room.

Fire safety checks viewed were unclear. For example, they showed fire door release checks were completed in April 2026 and were satisfactory. The record did not provide any information about what the checks involved. However, we found there were doors not closing properly and there were fire doors with holes in them where fire could potentially spread. Some of the door holes were filled in during our visit.

Care plans lacked clear instructions for staff on what they were required to do to meet people’s needs. This meant staff may provide inconsistent or unsafe care. For example, fluid records for those people at high risk of poor nutrition did not show the actual times fluids were consumed to show people had consumed these regularly. People’s repositioning records lacked clear instructions to show repositioning was managed safely.

The inhouse infection, prevention and control audit showed actions to be completed but no information about who was to complete them and when. The medicines audit did not cover all aspects of medicines to demonstrate they were being managed safely. We found issues relating to medicines that needed improvement.

Staff and ‘resident’ meetings took place where issues relating to the service were discussed. However, records of these meetings were not fully available during our inspection to show how often these took place and what was discussed. The provider forwarded notes of meetings following our inspection. The operations manager told us that satisfaction surveys had been completed in June 2025, and responses had been “pretty positive.” They also advised that the service kept in regular touch with families through “WhatsApp” groups.

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 operations manager worked with other organisations involved in people's care to help ensure people received a consistent service that met their needs. The provider told us this included mental health teams, social workers, physiotherapists, speech and Language therapists and dietitians. Referrals were either made directly by staff or through other medical professionals, such as the GP.

Staff understood the importance of sharing information with healthcare professionals such as when there were changes in people’s health. One staff member said, “The district nurse advises us, and we can ask any questions to help the residents as much as we can.”

Relatives confirmed people had access to healthcare professionals such as a practice nurse if needed.

The provider focused on continuous learning and improvement across the organisation and local system, but this was not always effective. They encouraged delivering equality of experience, outcome and quality of life for people.

Whilst the provider had implemented systems to support staff learning, these were not effective and did not ensure staff consistently applied their learning to ensure their practice was safe. For example, staff did not always follow best practice in relation to medicine management, infection prevention and control, environmental safety and fire safety.

There was however learning from incidents in the home. For example, where 1 person had fallen out of bed, this was managed by turning the bed the other way. Also, the provider told us how they had made arrangements to increase staffing where they noted 1 person needed extra support. They had also changed the timing of when medication was given and had reviewed job roles so that some tasks were moved to the night team. They reported how this had gone well.