Henford 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 79 (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 provider had a values statement and policies and procedures, setting out expectations on how staff should work. Staff were aware of these documents and where they could find them. Information was communicated to staff through their intranet and in regular staff meetings.

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 provider now had a registered manager in post and was in the process of recruiting to the vacant deputy manager post. The registered manager told us they were supported by a management team, including seconded cover for the deputy manager post during recruitment. Staff told us they felt supported by the management approach.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us there were effective systems for them to raise any concerns and they felt confident action would be taken if they used them. Information about how to raise concerns was displayed in staff areas of the building and on the provider’s intranet. Records demonstrated staff were encouraged to raise any concerns during team meetings and individual meetings with their supervisor, which were followed up.

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 provider had processes in place for staff to request flexibility in their work patterns, for example to enable staff with caring responsibilities or those with health conditions to remain working. Staff were aware of these processes and told us they felt supported by the management team.

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. At the last inspection we identified shortfalls in the governance systems. At this inspection we found this had improved. There was a range of monitoring and auditing systems used by the provider, including feedback from people and their relatives, feedback from staff and observations of staff practice. The registered manager completed a monthly clinical governance report, with input from senior staff in all departments of the service. Audits included falls, pressure injuries, nutrition, training and competency for nurses, distressed reactions, infection control and medicines. This information was now used to create a central action plan, which had named staff responsible and a timescale for completion. The plan was regularly reviewed by the registered manager and regional director to ensure actions had been completed.

The provider clearly understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement. People and relatives gave examples of the service working in partnership with other agencies, including community nurses, occupational therapists and specialist nurses. Professional partners gave positive feedback about their experience of working with the service to meet people’s needs. A development manager of a specialist Parkinson’s support service told us, “[Registered Manager] is driven and pioneering to ensure the residents and community are connected and all receive great care. [Registered Manager] welcomes opportunities and is often the driving force behind ideas to work collaboratively in order to benefit the community and residents. [Registered Manager] takes pride in delivering great care and opportunities and is resourceful. [Registered Manager] worked with us to pilot a Parkinson's social group for 6 months which was successful and is now a regular part of the activities on offer at Henford House. It welcomes people affected by Parkinson's from the local community as well as residents, the outreach is excellent.”

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. Systems for monitoring standards of care were used to identify areas of improvement and lessons learned. This included regular audits and quality assurance checks. The provider had systems to share learning from incidents in other services.