Handford House Care 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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment this key question was rated inadequate. 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.

At our last assessment we found the provider was in breach of legal regulation in relation to the governance of the service. We found there were widespread and significant shortfalls in leadership, in addition the rating overall was inadequate with multiple breaches of regulation. At this assessment we found the provider was no longer in breach of regulation and ongoing improvements were being made. However, these needed to be embedded in practice and sustained.

There had been a change in management since our last assessment and we received feedback that improvements were being made in the governance of the service.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Improvements were being made which needed to be embedded and sustained in practice. 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.

Since our last assessment improvements had been made. The majority of staff told us they felt the service was improving and they felt listened to and valued. However, we also received some feedback from 4 staff members who felt the culture needed to be improved. The manager told us they had an open door policy where staff could speak with them as they needed to. Staff were now being provided with 1 to 1 supervision meetings to receive feedback about their work, discuss any concerns and identify any training needs. Heads of departments had been supported and empowered to deliver 1 to 1 supervision with the staff in their department.

A range of staff meeting minutes, included whole staff, clinical, nutrition and health and safety meetings, showed staff were advised of their role and responsibilities and were kept updated with any changes in the service. Where concerns were identified relating to people, actions were agreed in how to monitor and reduce risks. All of these meetings demonstrated staff were engaged in the shared direction and culture of the service.

Policies and procedures and staff training were in place relating to diversity and inclusion.

Improvements were being made which needed to be embedded and sustained in practice. 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.

Since our last assessment, the registered manager had left the service. There was a new manager in post since October 2024. They told us they had sent us their registered manager application and received confirmation this was being processed. The manager was enthusiastic, compassionate and understood their role and responsibilities. They were open with us and told us about the improvements made and those which were ongoing and not yet fully implemented.

We received feedback from people, relatives and staff, in how the manager was accessible, listened and they could see improvements were being made. A relative told us, “[Manager] has made a big difference in terms of improvements and leadership within the home.” Another relative said, “There is now a new manager in place and there have been improvements. Still more to do though.”

The manager told us they were on call when not in the service if staff required advice or guidance. There were also other members of the management team, including the clinical lead and deputy manager who could be called upon to attend the service if required.

Improvements were being made which needed to be embedded and sustained in practice. The provider fostered a positive culture where the majority of staff felt they could speak up and their voice would be heard.

Staff told us there was a whistle blowing policy in place which they understood. The majority of staff told us they felt listened to and would report concerns. Notices were posted in the staff area on the second floor relating to speaking out and support available. This included notices relating to the provider’s zero tolerance relating to sexual harassment.

Staff surveys were conducted, where staff could complete them anonymously if they chose to. Actions were taken as a result of staff comments, this was posted on a notice board in the staff area which showed how their comments had been valued and listened to, which included improving communication. The majority of comments stated how improvement were being noted by staff, with a staff member saying how they were feeling pride in how the service was improving. However, there were some staff who reported they did not feel confident speaking out and were not always listened to.

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.

There were systems in place to ensure staff were aware of the support they could access both inside and outside of the home where required. This included helplines they could use for support.

There was a diverse staff team working in the service and open communication supported equality and a fair culture. However, we received some feedback from staff where they felt there were cliques within the staff team and not everyone was treated equally. We observed staff working together and communicating effectively with each other during our visits. This included a staff handover meeting, where people’s wellbeing was discussed and actions required for the shift were allocated equally between the team.

Improvements were being made which needed to be embedded and sustained in practice. The provider now had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support.

Since our last assessment improvement had been made. Audits and monitoring supported the management team to independently identify and address shortfalls. However, we had noted that records of blood sugar monitoring had gaps which had not been picked up in the provider’s own monitoring systems, action was immediately taken to address this once pointed out. The provider had implemented call bell analysis, this supported the management team to identify that people were supported when needed. The analysis included how many times call bells were used and any call bell response times which exceeded the provider’s set acceptable timescales. Lessons were learned, including increasing 1 to 1 social stimulation and checks to provide reassurance.

The provider’s newsletter from August 2024 included guidance on statutory notifications and actions to be taken within 24 hours of an incident resulting in serious injury. The document included information about regulation managers and the clinical support team within the organisation, and the support they provided to the locations within the organisation.

Action plans were in place where improvements needed had been identified by the provider. Where improvements were made these were documented. This included where gaps had been identified in repositioning records, this was being kept under review and monitored daily.

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.

We received positive feedback from social care professionals relating to how the service worked with them. The service had accepted guidance and support, including workshops in areas such as reporting and recording. A recent assessment undertaken by commissioners showed their rating of the service as good. The management team showed us an agreement made with the local authority who had made the decision to start to commission with the service, where this had been previously suspended until improvements had been made.

The manager told us they worked with social care and health care professionals to improve the service provided to people and to ensure a consistent service was received. The manager told us how they had a meeting with the GP surgery regarding the services people received. Ongoing contact was maintained to ensure an effective working relationship.

Where people had attended appointments with health professionals, the dates of these, recommendations for care and the outcomes were included in care plans to ensure people’s care needs were being met consistently.

Improvements were being made which needed to be embedded and sustained in practice. The provider was focussing on continuous learning and improvement across the organisation and local system.

The management team told us about the improvements they had made since our last assessment, which were ongoing. Not all of the planned improvements were fully implemented, embedded and sustained in practice. They had an improvement plan in place, which demonstrated their commitment to improve the service. We saw a plan which identified the learning to reduce the risks of a deterioration in the service as identified at our last assessment, this included ongoing monitoring and support to sustain the improvements made.

There was a policy of the week, which staff were required to read and sign policies and procedures to show they had read and understood them. The policy of the week for our first visit was relating to dementia.

Improvements had been made to the staff training. The gaps identified at our last assessment had been addressed. In addition to the eLearning programme, staff were receiving face to face training, which the manager told us was tailor made to the service to ensure staff received the training they needed to meet people’s needs.