Haddon House Nursing 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 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 inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance and oversight.

This service scored 36 (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 not ensured their vision, strategy and culture was understood and demonstrated by leaders and staff at all levels.

The culture within the home did not promote ownership, accountability or collective responsibility for people’s safety. During our assessment, some staff viewed concerns raised as the responsibility of others and there was a lack of follow up. This resulted in issues being passed on or left for others to address, sometimes not being addressed at all. On a number of occasions during our assessment, the inspection team had to ask for specific action to be taken following concerns raised as we were not assured this had been considered. This placed people at risk of harm.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation.

Leaders delegated responsibilities without assuring themselves that staff were sufficiently supported to undertake them. When tasks were not completed, leaders attributed this responsibility to staff rather than considering whether the appropriate oversight, or support systems were in place. For example, following our first site visit, the provider submitted an action plan confirming some of the concerns identified during the assessment had been addressed. However, when we returned the following week, we found issues remained unresolved. The provider explained they had been advised that the actions had been completed by previous management but had not undertaken any checks to confirm this. This highlighted a lack of accountability for ensuring risks were effectively addressed.

Staff told us they had lacked confidence in management. One staff member suggested that leaders needed more visible presence on the floor, as they were not always aware what was happening across the service.

The provider was present during the site visits, receptive to our feedback and took some immediate steps to improve safety. This included changes to the management team following our first site visit. A new manager, clinical lead, and increased provider presence was brought in to strengthen leadership, oversight and support to address the concerns found during our assessment. Staff told us they felt confident in the new leaders.

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

Staff understood their responsibility to speak up, however not all staff felt they had suitable opportunities to share concerns, or that these would be acted upon. One staff told us they wanted more one-to-one supervision sessions to raise concerns and discuss issues.

During our second site visit we were assured plans to ensure staff were supported to speak up, this included additional meetings to include care staff.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Whilst some staff felt they were treated fairly, others felt previous management had favourites within the staff team. For example, a member of staff shared they felt the previous manager failed to adequately address sickness absence, or poor practice for some of the staff team. Relevant policies and training were in place to support equality, diversity and human rights.

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

There were significant shortfalls in the provider’s systems to oversee risk, quality and drive improvements at the service. For example, a range of audits and governance checks were in place and routinely completed, however leaders had failed to identify or take effective action to address the concerns identified during our assessment. This included risks associated with medicine management, skin integrity, modified diets and behaviour management.

The provider’s policies and procedures in place to ensure safe service delivery were not consistently followed. This placed people at risk of harm.

During our second site visit, the provider confirmed they would increase support at senior leader level and ensure clear accountability for overseeing improvements in governance systems.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Although the provider understood the importance of working in partnership, and engaged with relevant authorities and agencies, they did not always take timely and effective action to address concerns or make improvements following their feedback. For example, the provider had informed the local authority that action had been taken to address identified concerns. However, our assessment found some of these issues remained unresolved. This limited effective partnership working.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

Systems to drive improvement were not effective. When safety concerns were identified through audits or checks, action to improve safety was not always taken. This placed people at risk of harm. For example, a routine provider audit had identified on 3 consecutive months prior to our assessment that a full wound audit was needed to reduce number of skin tears, bruises and pressure sores. Each month a timescale of 1 week for completing this audit was given, however there was no evidence these wound audits had been completed. During our assessment we found ongoing concerns regarding the management and recording of skin integrity issues. Following our first site visit, the provider told us they had completed a full wound audit. During our second site visit, we asked for a copy of this audit, however the provider could not locate it. This meant the provider could not demonstrate this action had been completed, placing people at risk of harm.

During our assessment, the provider confirmed additional senior level support and clear accountability for driving improvements would be implemented to address the areas of concern we identified.