Haresbrook Park 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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to the governance at the service.

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.

The provider’s vision, mission, and values were clearly outlined in the statement of purpose. Staff reflected these aims in their working practice, which we observed. Staff and leaders promoted a positive culture and were committed to providing a quality service to the people they supported. The provider demonstrated respect for people’s human rights and valued diversity within the organisation. Staff spoke positively of the leadership team and their roles within the service. A staff member said, “Managers and staff are all very supportive.”

The registered manager and all staff had a good understanding of their roles and shared a commitment to providing person centred care and treating and valuing people as individuals. A range of policies were in place to guide staff.

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 and credibility to lead effectively.

While there had been positive developments since the last inspection, with leaders becoming more visible and approachable, this was not yet fully embedded across the service. The systems and effective oversight processes needed improvements. At the time of the inspection, the service was in breach of 2 regulations relating to safe care and treatment and good governance.

People, relatives and staff were complimentary of the registered manager. One person’s relative told us, “The manager is lovely. Her leadership is very good. She’s easy to speak to, listens and gives feedback. She is knowledgeable. She has a firm side to her to keep the place running.”

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

There was a whistle blowing policy in place and staff knew how to raise concerns. Staff told us they felt the management team were approachable and that they would talk to them if they needed to. A member of staff provided us with an example on how the registered manager listened to their concerns. The member of staff told us, “Have voiced my concerns that staff just do an hour of one-to-one support. The registered manager agreed with this and amended staffing levels.”

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.

The provider’s policies and procedures promoted equality, diversity, and human rights. Staff had completed equality training to improve their understanding of protected characteristics and awareness of bullying and harassment. Staff told us the management team was supportive, inclusive, and fair to all staff. The provider fostered an open environment where differences were recognised and respected, and staff felt able to raise concerns without fear of discrimination.

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

The provider failed to maintain securely an accurate, complete and contemporaneous record in respect of each service user. Some information within care plans has not been updated following changes in people’s wishes or conditions.

There were processes in place to check the quality of the service and identify shortfalls. However, these had not always been effective in identifying issues related to care planning, infection prevention control or staff’s understanding of International Dysphagia Diet Standardisation Initiative (IDDSI). IDDSI is a globally recognised framework that standardises food textures and drink consistencies to help people with swallowing difficulties eat and drink safely.

Following concerns raised with the registered manager and provider, action was taken to support improvement and strengthen the oversight of the service.

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.

People and their relatives told us that the service developed positive relationship with local community and external agencies. A person’s relative told us, “The church comes in. Doctors and nurses come. They have a singer and other activity visitors come. They have relatives/residents meetings about every 3 months.”

A healthcare professional told us, “I have always found the staff very welcoming and professional, they always have time for me, and I feel they know their resident's well. It is lovely to go to the home and see the relationships the staff have with residents and wonderful to hear the laughter shared. I feel [registered manager] and her team are fantastic advocates for their residents and I often see them going above and beyond to ensure all of the residents' needs are met and to ensure they have a good quality of life.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

Some issues identified during our previous inspection had not been recognised or resolved through existing monitoring processes such as the concerns found with the safe management of medicines. Although audits and checks were completed, they did not consistently provide leaders and managers with sufficient oversight, assurance or evidence that required actions were implemented, embedded and leading to measurable improvements in people’s care and outcomes.

Further work was needed to establish a consistent culture of learning, innovation and continuous improvement. The provider showed an understanding of how to improve the service and had responded promptly to the shortfalls identified by taking immediate action to address our concerns.