Hallmark Midford Manor Luxury 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 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 75 (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 had a clear vision and core values charter which staff were aware of. The business plan identified and analysed the strengths, weaknesses, opportunities and threat (SWOT) for the service over the next year. Leaders monitored and reviewed the progress of the plan with other stakeholders regularly. Communication methods were in place for strategic information to be cascaded to the service and the teams. The newly appointed registered manager told us, “The culture amongst the senior management team is one of the best I have experienced, the structure and support they have on offer is exceptional.”

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. There had been a change of leadership in the service with a new regional team being assigned to the home and a new registered manager. Staff felt positive about the future of the service and were looking forward to having stability in the service after experiencing a few different managers in a short period of time. One staff member told us, “The manager started about 2-3 weeks ago and they were happy to hear about the concerns we have around staff morale within the service.” The manager told us they had received excellent support from the senior leadership team since they started in their role. We received positive comments about the registered manager from professionals, people and relatives.

Staff did not always feel they could speak up and that their voice would be heard and we received mixed feedback. For example, some staff told us they did not speak up with senior leaders due to the fear of recrimination. Where they had seen other staff members raise concerns previously, they felt management did not listen or did not do anything about it. However, staff told us they were able to speak directly to senior staff or team leaders. Staff also told us there was a suggestions and feedback box located in the main foyer, but they did not always hear about any of the ideas or suggestions. The provider submitted evidence to show they had provided information about suggestions and how they had fed back to staff. Staff told us there had been lots of changes in the management of the service and they were looking forward to building a stronger relationship with new leaders so they could discuss their concerns. They felt there had been an improvement in recent weeks. Leaders told us they were aware of these issues and had been working more closely with staff and HR. The registered manager spoke about their commitment in strengthening their approach to ensure staff felt able to speak up under their leadership. There were systems available to allow people, relatives and staff to speak up and have their voices heard. For example, there was a whistleblowing policy, HR clinics, regular team meetings, supervisions and surveys being completed.

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. There were policies and procedures to support workforce equality, diversity and inclusion. The provider had an equality, diversity, inclusion and belonging strategy (EDIB) in place which included intentional activities in the service such as EDIB workshops and learning opportunities to foster an inclusive team environment. Staff had access to several resources to expand their knowledge on cultural differences and creating a sense of belonging for everyone. The service created opportunities to celebrate different cultures and there was work happening to ensure the policies were inclusive and accessible. One of the action points of the EDIB network group was looking into the allocation of shifts for staff to ensure they were fair and equitable for everyone. One staff member told us, “I think people are treated fairly and equitably. Wherever we are from, we need to be heard and seen.”

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. For example, the infection, prevention and control (IPC) concerns we found had not been identified by the provider. The provider’s systems and processes had not identified where staff had not maintained monitoring or completed recordings of people with an identified risk. For example, in relation to a person who was at risk of dehydration and malnutrition and for another person where the care plan stated bowel monitoring should be in place.

However, there were a range of other regular audits taking place in the service which were effective in identifying concerns. For example, audits of call bell and falls analysis was being completed regularly and there were action plans in place. There was a policy and procedure for the availability, integrity and confidentiality of data, records and data management systems. The provider had a service improvement plan which identified areas of improvement. There was a business continuity plan which identified areas of risks and what to do in an emergency.

The provider clearly understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement. People told us the service worked with professionals on their behalf. Professionals confirmed the service worked with them to develop and improve care for people, highlighted the added benefits and the sense of community within the service. People had regular visitors to the service, and we saw family and friends visiting on the day of the inspection and enjoying the communal areas such as the café where they had access to free drinks and cakes. The outside area had a child play area, and there was a cinema and hairdressing room on-site. Each floor within the home had lounge areas, a dedicated dining room and social cocktail lounge area for people and their families to access.

The provider had established links with a variety of community groups such as the local Hospice, Theatre, Bath in Bloom and Macmillan. Professionals visited the service to provide a series of ‘lectures’ to people on topics such as falls prevention and oral care. There was a wide range of meaningful activities on offer such as yoga, croquet and boules, music and movement and baking. Church services were arranged in the home which people participated in. A local charity became involved with the service after a person wanted to get actively involved in cycling. Regular cycling outings were organised where people could access specialised bikes to meet their needs. Feedback from a relative included, “[Person] told me about the trip and the ride on the tricycle. They sounded so much better after it and loved telling me all about the tricycle ride.” Intergenerational activities were taking place in the service such as family Halloween treasure hunts and a local nursery coming in monthly to complete different projects. People told us how much it benefitted their wellbeing by seeing younger people in the service. Some people were part of the recruitment process for new team members, and 1 person told us how this made them feel part of the service they lived in and how it made them feel like they were contributing to the 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. There were clear processes for people to provide feedback on what they would like to happen in the home. The home was decorated to a high standard, and the original design of the building included the involvement of dementia specialists. There was dementia friendly signage visible for people to navigate the environment easily. People who chose to reside on the second floor of the building had access to their own bedroom with a walk-in wardrobe, kitchenette and dining area. The new regional team and registered manager had started to work on improvements within the service, and they told us they were looking at areas such as relocation packages for staff on sponsorship licences and filling the vacant bedrooms in the service.