Harefield Lodge

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 there were widespread and significant shortfalls in service 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. The providers governance system failed to identify all the concerns we found during this inspection.

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.

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.

Processes were in place to promote equality and diversity for people and the staff team. The provider’s statement of purpose clearly set out their values.

The registered manager told us, “Our ethos is empowering together, outstanding and supportive. Supporting people to live their lives and do what they want. To ensure they are given choices and opportunities.”

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.

We identified breaches of regulations and concerns in governance. Leaders had not independently identified and acted on all these concerns prior to our inspection. This meant some development was needed in their skills and knowledge to lead effectively.

Relatives told us they were informed of incidents involving their relatives and communication with the registered manager was good.

Staff members told us, the registered manager was visible, accessible and approachable.

The provider fostered a positive culture where people and staff felt they could speak up and their voice would be heard.

People living in the services were asked for their views and were given the opportunity to speak up on a daily basis both informally and in meetings. The registered manager told us action plans were devised from these conversations. This meant people’s views were listened to and drove improvement.

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 felt supported to give feedback and were treated equally, free from bullying or harassment. They told us they had access to relevant policies.

The registered manager told us about the organisation’s flexible working policy which meant staff could apply for adjustments in their work to be made if needed. They gave examples of when this had happened in practice.

The provider did not have clear responsibilities, roles, systems of accountability or good governance operating effectively at Harefield Lodge. They did not always act on the best information about risk, performance and outcomes.

The provider’s own governance systems had failed to identify people were not always receiving effective, compassionate care and therefore prompt action had not been taken to make improvements.

Whilst quality assurance audits had been completed, these had not always been effective in identifying the shortfalls we found at this inspection, such as care plans and PRN protocols not containing the correct level of detail to support people safely, PEEPs not being person centred, the lack of future care planning, staff not having specific training to aid with a person’s medical condition and recruitment practices not in line with current legislation.

Although the registered manager was responsive to our concerns, they required time to embed any actions taken into practice.

People did not always receive care and support in accordance with the principles of ‘Right care, right support, right culture’ guidance. However, people were given choice and treated with dignity and respect and were supported to engage in meaningful activities both inside and outside of their home.

The registered manager was able to confidently tell us how they ensured safe record keeping by following the principles of General Data Protection Regulation (GDPR).

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.

Professionals, staff, and the registered manager shared with us positive examples of collaborative working in partnership. One professional told us, “The service has demonstrated a collaborative approach and has been open to professional input. This partnership working has contributed to positive outcomes for the person I have been involved with.”

The provider strived to focus on continuous learning, innovation and improvement across the organisation and local system.

However, we found some concerns during the inspection which we have highlighted throughout our report. Although the provider was motivated to learn and improve the service for people, their overall ambition was limited by the ineffective operation of risk and quality monitoring systems at Harefield Lodge. This meant they might not always be aware of shortfalls to enable prompt improvement and learning.

The registered manager was responsive during our inspection and told us what action they would be taking and how they were taking learning from this inspection and would be sharing this across their organisation.