Hadfield 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 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.

This service scored 54 (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 demonstrate a positive, compassionate, listening culture that promotes trust and understanding.

At the time of the inspection, the provider had made some changes to staff’s shift patterns. Some staff had concerns about the new shift patterns which they had raised with the local authority. Senior leaders explained how they had followed appropriate procedures to ensure this change had been completed fairly and in line with legal requirements. However, due to this change, we did find that some staff were unhappy and felt demoralised.

The registered manager had held a staff meeting and completed specific days in which staff were able to visit them to discuss any concerns. This had been completed in response to our findings and was not proactively initiated.

The provider had not completed recent staff surveys or questionnaires. The provider should seek the views of staff and analyse and respond to the information gathered to improve the service. Following our inspection, staff questionnaires have been developed and sent out to staff.

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

The leadership team had failed to demonstrate effective oversight of their responsibilities. For example, they had failed to submit statutory notifications to CQC following allegations of abuse and deaths. They did not have effective oversight of incidents, concerns or safeguarding incidents. Mandatory training completion rates, risk assessments and care plans required some improvement. Staff were not always up to date with their documentation regarding people’s observations.

However, the leadership team were proactive with concerns we raised, and these had been actioned or were being actioned at the end of the inspection.

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

Although most staff told us they felt able to raise concerns with the registered manager, various staff told us they did not feel listened to by the provider. Various staff told us they did not feel heard regarding recent concerns they had regarding their shifts changing. Some staff also raised concerns regarding whistleblowers not remaining anonymous within the service and senior leaders trying to discover who had raised concerns, instead of focusing on the content of the concern.

Residents and families told us they knew how to raise concerns and felt able to do so.

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 raised no concerns regarding discrimination. Most staff told us they did not feel there was a culture in which bullying occurred.

Some staff told us the registered manager would support them with working around medical appointments and would try to offer flexibility. However, they also stated the provider was less flexible in their approach.

The provider had an equality, diversity and inclusion training package but not all staff had completed it.

The provider did not have good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The registered manager was unclear on their regulatory responsibility in relation to submitting statutory notifications. Following the feedback provided, the registered manager submitted the outstanding statutory notifications retrospectively.

The service did not have an effective system for the management review of incidents. This meant managers were unable to demonstrate that incidents were routinely reviewed to identify themes, monitor trends or ensure appropriate action had been taken to reduce future risks.

The service did not have effective systems to monitor staff competence and compliance. The oversight of mandatory training completion needed to improve. Staff supervision and annual appraisals had not been completed consistently which limited the registered managers ability to monitor performance, provide support and identify developmental needs.

The service did not have effective and robust auditing systems and processes. Audits had not identified that people’s care plans and risk assessments were not up to date, were missing key information and how some lacked in detail. Furthermore, monitoring documentation relating to people's nutrition, hydration and routine observations had not always been completed. Incomplete records reduced assurance that people's health needs were being consistently monitored and responded to.

Governance processes relating to medicines management were ineffective. Medication competency assessments could not be evidenced for relevant staff, some ‘when required’ medication protocols were missing, despite provider audits recording these needed to be improved. This demonstrated that actions from audits were not consistently being followed up.

Legal documentation was not consistently maintained. Consent forms were not always in place for people living at the service, meaning the provider could not demonstrate that care was always delivered in accordance with people's wishes or legal requirements.

Following the initial feedback, the provider implemented an audit schedule and appropriate paperwork. The registered manager was confident they could complete all audits now there was a schedule in place and they felt more organised. The lead senior was also taking on some tasks to support with governance and oversight of the service. Although the provider had been responsive to our feedback, the new systems and processes were untested and needed to be embedded.

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 attended local authority forums and was well known within the local network which supported opportunities for shared learning and best practice.

External professionals were mainly complimentary about the way the manager and staff shared key information with partners.

The provider did not always focus on continuous learning, innovation and improvement across the organisation.

The provider failed to demonstrate continuous learning and improvement. Although concerns and incidents occurred within the service, there was no evidence these were routinely analysed to identify recurring themes or trends.

The provider was asked to provide their most recent analysis from staff and resident surveys or questionnaires. The provider failed to provide these, suggesting they had not been completed. It is important that providers actively seek the views of a wide array of people, including staff, people and relatives who use the service and analyse the findings to drive improvements.

The provider was completing internal audits which had not identified various issues which had been picked up on this inspection.

The provider had not responded to a local authority medicines unannounced audit which had identified concerns with ‘as required’ medicines protocols needing a review and an update. Despite this, issues with such protocols have been identified on this inspection.

Following the initial onsite feedback, the provider made various improvements to systems and processes which they were hopeful would ensure better oversight and learning. For example, the provider had paperwork for recording incidents and post incident reviews. In addition, the provider had completed an action plan in relation to recent audits.