Archived: OSJCT Henlow Court

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 –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 remained 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 continued to be in breach of the legal regulation in relation to good governance.

This service scored 57 (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 did not always have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They told us they were working towards understanding the challenges and the needs of people and their communities.

Staff told us they recognised the providers commitment to improving the service and wanted to be part of the journey forward.

The provider was offering staff engagement sessions and giving staff an opportunity to be involved in shaping the service going forward. However, staff we spoke with felt they were not being listened to and did not feel managers were present enough on the floor to support staff. A staff member told us “"Staff are not happy, morale very low" and another staff member told us "There is a lot of unhappiness now.”

Some staff were supported with supervision from clinical staff who worked elsewhere within the organisation. We were given assurances staff would be provided with supervision by managers who had the right skills and knowledge to support them who worked at the service going forward.

Not all leaders understood the context in which the provider delivered care, treatment and support. 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.

At the time of the assessment the home was going through a period of transition with no registered manager in post. This appeared to be impacting on staff. However, the provider had ensured there was sufficient management cover during the transition period. We were given assurances going forward that there would be a registered manager in post and leadership support during the new manager’s induction period.

People did not always feel they could speak up and that their voice would be heard.

Some Staff we spoke with told us they did not always feel listened to as team members. Staff meeting minutes we viewed did not reflect a non-judgemental, open and inclusive employer.

We observed information within the home that gave staff advice on how they could report concerns.

There were processes in place to support new emerging leaders and staff who want to further develop. There was evidence the provider had ensured there was management support at the home during the transition period where no registered manager was in post.

The provider had an equalities policy in place

The provider told us they operated an inclusive work environment, and accommodated staff needs where possible.

The provider had processes in place to support good governance of the service. However, these had not always been effectively followed and maintained. The provider had a service improvement plan in place which was regularly reviewed however we found the plan had not identified all the areas we found during our assessment. Accurate, complete and contemporaneous records were not always kept. Care plans were reviewed but not updated to reflect current abilities and the care provided and risk was not always escalated and recorded appropriately. We found however improvements innursing documentation and monitoring in recent months.

During our onsite assessment we identified one person who had had significant weight loss over a 3 month period. This had not been identified in previous provider audits. We raised this during the assessment and the service took the appropriate action. We identified one person’s weight record was incorrect, whilst a repeated weight measurement using a MUAC (mid-upper arm circumference) method had been carried out the result were not escalated. Following our feedback the service took action to address these concerns.

Many people living at Henlow Court were living with a dementia. Whilst this was reflected in the Statement of purpose the service registration on the Care Quality Commission website did not reflect this service user band.

A falls audit we reviewed highlighted the need for a person not to be left on their own following personal care in the morning. The dependency tool the provider used did not reflect the person’s needs accurately. The tool showed the person did not require any supervision. This may mean that the correct ratio of staff may not be deployed.

Rotas we viewed did not show the same number of staff on duty consistently. We raised this with the provider during feedback, and we were provided with a rota sheet that contained different information to that we had been given during the assessment. Therefore, it was difficult to understand exactly what was happening with staffing levels at the service.

Agency staff were used to cover gaps in care shifts. The provider gave us assurances that the agency staff working at the service had the necessary skills, qualifications and security/criminal checks. Most of the agency profiles we viewed demonstrated the providers policy and national guidance. However, we found an agency profile with an enhanced DBS (disclose barring service) which had not been updated since January 2015. This is important as the provider is responsible for safety and well being of people in their care.

The provider was working to improve consistency in care delivery. Most people told us they thought the home was well run and the management approachable. One person told us “I think that things are managed well because it is all quite smooth here.” And another person told us “The manager comes and says hello and asks if everything is alright.”

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. We received some feedback from professionals working with the service with some highlighting the good work the service was doing with people who lacked capacity to make decisions about their care and some improvements with communication at the service. One professional told us “a resident, who experiences cognitive difficulties due to dementia, wanted a staff member present whilst I spoke to them to complete a Mental Capacity Assessment; this staff member was observed to be sensitive and caring, when supporting the person, during the conversation had."

The provider did not always focus on continuous improvement across the organisation and local system. The provider carried out unannounced out of hour visits to the home, information from these visits fed into the service improvement plan. However, these onsite visits did not take place at the weekend. We asked what was in place to monitor the service at weekends, we were told the service had a robust on call service operating remotely. However, the provider could not demonstrate they had assurances for the care people received during weekends. Some feedback from relatives highlighted inconsistencies with people’s experiences some of the time. One relative told us “Quite a few during the week about at the weekend I stood outside for half an hour waiting to be let in. Perhaps not so many staff at weekends” Another told us “I think on the whole things work well for people when the management are around when they aren’t there, I don’t feel so comfortable.”