Signature at Hendon Hall

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.

This is the first assessment for this newly registered service. We rated this key question 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 68 (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.

There was a positive culture at the home, amongst the staff team, heads of department and the leadership. Staff felt able to speak up and they felt supported by senior staff. People spoke of their enjoyment living at Hendon Hall and also felt they could raise issues.

We found some shortfalls at this assessment; the registered manager and senior staff took this feedback positively and made plans to correct these issues.

The provider had inclusive leaders at all levels who understood and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively.

People and their relatives spoke well of the registered manager. They found the registered manager compassionate and dedicated. Staff spoke highly of the senior staff and heads of department they worked with daily. Leaders had created a positive culture, where they promoted people’s wishes and quality of life.

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

Staff told us they felt able to do this. Relatives gave examples of their positive engagement with the registered manager and staff when they wanted to raise issues important to them.

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 gave us examples of when leaders were flexible with their shift patterns to enable staff to manage situations in their personal lives. Staff who came from overseas to work were supported by safe recruitment checks completed by personnel staff at the home.

The provider had clear responsibilities, roles, systems of accountability and key aspects of good governance. But there were some shortfalls in their governance, systems and the work completed.

There were effective audits taking place in many of the key areas of the care provided. Such as the dining experience, entertainment, appearance and hygiene of the home, staffing levels and staff culture. However, there were also shortfalls in some important aspects of care. Such as ensuring people who were at risk of choking received their assessed correct textured meal. Those at risk or who had pressure damage to their skin were not always sleeping on air mattresses which were set to the correct level. Some risk assessments and accompanying care plans, especially for high-risk areas such as the use of oxygen and those at risk of developing skin pressure damage, the risks had not been robustly assessed with effective care plans put in place. The day-to-day aspects of safety such as the safe storage of some PPE items, cleaning products, aerosols, were also not always safely managed. At times staff and leaders were knowledgeable and following the provider’s own polices on certain subjects.

These issues had the potential to place people at risk of harm. The registered manager and provider representative did give verbal and written assurances that actions would be taken to correct these shortfalls.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. But they did not always seek this input when it was needed.

Leaders were clear about this role. Clinical leads and nurses did collaborate with health professionals to manage people’s health needs. However, there were missed opportunities at times. Consultation with the health professional regarding the choking need and consideration of involving a dementia specialist organisation was not sought when staff had exhausted their own knowledge base.

The provider had a focus on continuous learning, innovation and improvement across the organisation.

The provider had created systems to promote further learning and improvement. The registered manager had a working action plan which is good practice. We saw examples when improvements were required the learning was shared with staff and nurses. Sometimes the learning opportunity was missed due to shortfalls in the quality monitoring of the service. However, the registered manager and provider responded well to our feedback during this assessment and told us they would address the shortfalls found.