Hawthorn Manor Residential 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 remained 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 71 (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 management team were enthusiastic about the roles they played in making sure people received good care and how they supported staff to achieve this.

The registered manager led a positive culture and worked with staff to make sure they understood their values and expectations. People and their relatives gave positive feedback such as, “(Name) the manager keeps us updated with any relevant information”, “Best home I have been in” and “I believe it is it is very well organised.”

Staff gave positive feedback about the culture of the service. Staff reported a positive open culture where they felt able to raise concerns or make suggestions. Staff were happy in their role. One staff member told us they had left to work elsewhere but returned when they found the culture at Hawthorn Manor was preferable to them.

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 registered manager led a team which included senior carers and care staff as well as ancillary staff. The registered manager told us they had a good team who were committed to their roles and worked well together, ensuring a holistic approach to meeting people’s needs. Staff were equally positive about the support they received from the registered manager.

The registered manager told us they were well supported by representatives of the provider’s senior management team. They visited regularly, providing support and to check on the quality and safety of the service.

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

When complaints had been made, these had been responded to appropriately to ensure people or relatives felt they had been listened to and heard. People and their relatives told us they knew who they would complain to if they needed.
Comments included, “I would write or speak to the manager”, “(Registered manager) but I usually speak to (deputy manager)” and “I would speak to the manager.”

Staff said they felt comfortable to speak up if they had concerns. Regular one to one supervision meetings were held with staff, which gave them the opportunity to raise concerns privately. Group staff supervisions were held to learn and hold an open discussion about specific topics, and regular staff meetings were held which gave another opportunity to raise issues and make suggestions.

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 told us they felt well supported and they felt communication was good which led to good team working and relationships. Newer staff told us they had been welcomed by the staff team, who included them and made them feel part of the team quickly.
Staff had the opportunity to take on added responsibilities, such as completing additional learning and training to be a champion of a specific area of care, such as dignity or pressure area care. The registered manager had introduced employee of the month. People and relatives were also able to vote for their choice each month which supported inclusivity and fairness.

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

The registered manager told us senior carers monitored people’s daily records, but confirmed this was informally, so not recorded to ensure responsibility and accountability. We found issues with the recording of people’s daily care, which meant they could not be relied on to provide assurance people were receiving the care they were identified as needing. This had not been identified by the management team or the provider’s quality team. The registered manager provided assurance they would take action straight away to put better systems in place. This is an area to improve and will be checked at the next inspection.

Although monitoring processes were in place to ensure safe medicines practice, we found issues that had been identified, such as PRN protocols not always being in place to provide guidance to staff when administering people’s ‘when necessary’ medicines, was still a concern despite action being taken. The registered manager provided assurance they would continue to pursue improvement in this area by providing further oversight.

The provider had a range of auditing systems in place to check the quality and safety of the service. These included a number of service level audits, which were the responsibility of the registered manager, and provider level audits, consisting of regular visits by the provider’s representatives. Records were well kept, showing comprehensive checks, including detailed action plans identifying who was responsible for the necessary action and when this had been completed.

The registered manager was aware of their responsibilities and successfully delegated some of these to appropriate staff. Services providing health and social care to people are required to inform the CQC of important events that happen in the service. This is so we can check that appropriate action has been taken. The registered manager had submitted the appropriate notifications within suitable timescales.

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 provider and registered manager worked closely with partners from health and social care teams to ensure people received the care and advice they needed.

Partnerships had been built with local community organisations and institutions. These included with local schools and nurseries whose students came to visit and people and staff visited them. Also, local college students undertook work experience at the service which formed part of their course work. There were also close links with a local former naval dockyard, whose staff visited the service and supported people to share their memories and had themed talks, and regular visits to a dementia morning at a local fast-food outlet.

The registered manager signed up to join local provider and manager forums with local authorities and Skills for Care.

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. They actively contributed to safe, effective practice and research.

Incidents and accidents were reported by staff, signed off by the registered manager and reported through the organisation. This meant there was an oversight of incidents by the management team and the provider.
The registered manager told us they had learnt from the areas for improvement found during the inspection. They took action straight away and developed a plan to make sure improvements to recording processes could be sustained.