Hyllden Heights 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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this newly registered service. This key question has been rated 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 provider used various mediums to share the values and objectives of the organisation. They used training, induction, team meetings, supervisions and appraisals. Staff received a copy of the provider’s handbook which contained the provider’s values and objectives.

Staff told us they felt included in the team and were comfortable to ask for guidance and support from their managers who were always ready to guide, and support improvement in their roles. A staff member shared an experience where a member of the management had showed them how to complete a task by doing the task with them. They commented, “The managers lead by example.” Another staff member said, “They are helpful and supportive also. If I need any help I do get support from them.”

We observed staff approach their managers for assistance and guidance. They discussed issues in a supportive and open manner. A professional told us, “The registered manager, deputy manager and senior nurses I regularly have contact with demonstrate strong leadership and commitment to high standards of care. Communication with them has always been positive. I also find staff are respectful and appear motivated to provide good quality of care.”

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 service was managed and run by leaders who were visible, approachable and effective. People knew who to speak to if they had any concerns. A person told us, “It’s a good place, I feel safe. They run it well.” Staff also knew who to go to if they needed support in their roles. A staff member commented, “The management are approachable. If I have any concerns they do listen and co-operate.” Another staff member mentioned, “They are doing their best in this home. They have different managers for everything. The service is functioning well.”

The registered manager and unit leaders held daily meetings to stay up to date on operational matters, particularly those influencing the quality of care delivered to people and the effective running of the service. Issues were collaboratively addressed and resolved.

The registered manager understood their regulatory requirements in line with their registration. They had notified CQC of incidents in line with the requirements of their registration.

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

Staff told us they felt confident to discuss their concerns and express their grievances within and outside the organisation. A staff member told us, “I know the procedure to report my concerns or abuse or anything that is not right. I will report it to management and document it or I can report to the safeguarding team and CQC.” Another staff member said, “I always bring issues I’m not happy about to the registered manager or deputy manager. I feel comfortable to speak to them. They are always available to hear us. We can also raise concerns in team meetings.”

The provider had a policy and procedure which supported staff to speak up about the organisation. The registered manager told us they operated an open-door policy, and they always welcomed staff and visitors to speak to them and raise their concerns at any time.

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 and records showed staff had completed training in equality and diversity and they felt supported in the team irrespective of their background. A staff member commented, “I am getting good support here from my unit manager. The team is good and supportive. If I have any problems, I can approach the deputy or home manager.” Another staff member mentioned, “It is a safe place to work. If I have any personal issues or need a holiday or need changes in the rota they help us. They inspire me to work harder here.”

The registered manager told us they provided training and mentoring opportunities to help staff who were interested in developing and progressing in their roles.

The provider’s governance systems were not always effective in identifying gaps in the service.

The quality of the service provided was regularly monitored and assessed. Checks and audits completed included health and safety, medicines audits, care records, call bell audit, staff training and supervision audit, pressure sores monitoring, falls monitoring, incidents and accidents. We found that repositioning charts for people were not always completed for those who required it as part of their care plan to prevent pressure sores. We also found care plans that had not been updated to reflect the people’s current circumstances. We discussed this with the registered manager, and they acted on these issues immediately.

The service conducted monthly clinical governance meetings with the management team to review audit findings, identify emerging patterns and trends, and implement targeted actions to address areas in need of improvement. For example, medication retraining booked for staff and reflective practice done following medication errors identified.

The quality of the service was also discussed and shared with people, their relatives and staff during meetings. Their views on how to improve the service were sought and taken into account. People and their relatives had suggested about having a suggestion box in the home and this had been implemented. A person told us, “They are very good at making sure everything is good and well organised.” A staff member commented, “They do take suggestions into account. We have staff meetings with the management and relatives’ meetings. We always give feedback, and they do consider our feedback and take it on board. For example, I mentioned we needed a new equipment in the unit and we will received this straight away.”

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 service worked closely with local service commissioners, the NHS Clinical Commissioning Group as well as health and social care professionals to improve the service delivered to people. One partner shared the following feedback; “I have provided physiotherapy treatment in many different care homes over the years, and I can honestly say that Hyllden Heights Care Home is one of the best care homes I have been in. They provide wonderful care to the residents, enhance their quality of life with all the activities they provide, and they have treated me as part of the team from the moment I started visiting and providing physiotherapy input.”

The service actively collaborated with local and community organisations to provide activities and programmes that supported both individuals and staff. People frequently engaged with nearby community centres, church groups, and schools. This fostered meaningful connections and promoted inclusion within the wider community. For example, the provider was supporting a local school’s fundraising efforts to help deliver projects and organise activities for the care home.

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.

The registered manager was involved in the local council’s care provider network and the general managers’ provider group. They shared that they enhanced their knowledge and their practices to improve the service and the quality of care delivered.

The service regularly participated in both community-based and external programmes and initiatives aimed at making the home an active part of the community. The provider actively engages in numerous sustainability initiatives aimed at minimizing waste. They advocated for reduced paper usage and the adoption of eco-friendly products. Additionally, the provider was dedicated to continuously evaluating and implementing effective strategies for attracting skilled and experienced professionals, while placing strong emphasis on enhancing staff retention.