Heywoods Grange

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 changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care. The service was in breach of legal regulation in relation to governance.

This service scored 36 (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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities. Governance and oversight arrangements were not effective in identifying, assessing and mitigating risks. The provider had failed to establish robust systems to monitor compliance with the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards, resulting in the absence of decision-specific mental capacity assessments and appropriate authorisations for restrictions. Quality assurance processes had not identified concerns relating to medicines management, including gaps in competency assessments, medicines audits, oversight of pro re nata (PRN) medicines (medicines prescribed to be taken only when required), and medicines incident reporting. Long-standing environmental and fire safety concerns, including compromised fire doors, obstructed escape routes, storage of hazardous substances governed by the Control of Substances Hazardous to Health (COSHH) Regulations 2002, and unresolved risks identified following a previous kitchen fire, had not been identified or addressed through provider monitoring systems. Care plans, risk assessments and behavioural support documentation had not consistently been reviewed to reflect people's current needs, and specialist recommendations were not always acted upon or monitored. Several of the concerns identified during the inspection had persisted over extended periods without management action, demonstrating a culture that relied heavily on staff knowledge rather than effective governance, oversight and continuous improvement.
Relatives were generally positive about the culture of the home and described improvements over the previous year, particularly regarding activities and community engagement. One relative told us, "Things have improved in the last six months to a year," whilst another said, "They are doing the best with what they have." Staff demonstrated commitment to maintaining a homely environment and supporting people as individuals.
 

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty. Leaders did not consistently maintain oversight of service performance or demonstrate a clear understanding of the challenges facing the service. Information requested during the inspection was not always readily available, records were inconsistent, and relatives reported mixed experiences of involvement in reviews and decision-making.
Relatives spoke positively about some members of the leadership team and described them as approachable and supportive. One relative told us, "The manager is totally approachable," whilst another commented that management had been "very good" during their family member's admission to the home. However, quality assurance and governance systems had not identified several concerns found during inspection, including oversight of medicines, environmental risks and MCA/DoLS processes. This limited leaders' ability to demonstrate effective operational oversight and assurance.
 

People did not always feel they could speak up and that their voice would be heard. Relatives generally described staff as approachable and told us they felt able to raise concerns informally, with one relative describing a senior member of staff as "very approachable" and responsive when issues were raised. However, records showed that people's expressed views were not always explored or escalated. For example, one person's daily care record documented them stating they "do not feel safe with us lot". This significant expression of feeling unsafe had not been formally assessed, investigated or considered under safeguarding or speaking-up processes. As a result, the provider could not demonstrate that people's voices were consistently acted upon when concerns were raised.

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 had a stable and experienced workforce who spoke positively about their roles and demonstrated a strong commitment to the people they supported. Relatives consistently praised staff and described them as caring, approachable and understanding of people's individual needs. Staff worked together as a cohesive team and there was little reliance on unfamiliar agency staff, supporting continuity for both people using the service and employees.However, we found that staff did not always receive supervisions, and where staff had disclosed health conditions as part of their recruitment, there were no risk assessments in place to ensure staff were working safely.
 

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 information securely with others when appropriate. Quality assurance processes had not identified significant concerns relating to care planning, risk management, behavioural monitoring, staff supervision, medicines management, environmental safety and compliance with regulatory requirements. Records were not always accurate, or complete, and leaders were unable to demonstrate that information relating to people's care, health outcomes and service performance was routinely analysed to drive improvement. Although some actions were taken during the inspection in response to feedback, improvements were largely reactive and did not provide assurance that governance systems were effective in identifying and addressing concerns before they impacted on people.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with
partners or collaborate for improvement. The provider was unable to demonstrate consistent engagement with external partners to review and develop care and opportunities to learn, share information and improve outcomes through collaborative working were not always evident. This limited assurance that partnership arrangements were fully supporting people's changing needs and experiences. Relatives described positive relationships with staff and told us communication was generally open and supportive. One relative said, "communication is good both ways", whilst another told us, “The home very supportive, would be lost without them." Family involvement was a notable strength of the service and helped maintain continuity for people.
 

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. Information, learning and quality assurance processes, were not used to improve people's experiences, wellbeing and outcomes. Whilst staff responded positively to feedback during the inspection and took action to address some concerns, there was limited evidence that learning from incidents, complaints, safeguarding concerns, audits and day-to-day monitoring was routinely analysed and used to drive improvement. The service had not established formal systems for capturing lessons learned or reviewing care to identify opportunities for improvement. We found examples where known risks, identified concerns and monitoring information had not resulted in timely reviews of care, risk assessments or support arrangements. We found several missed opportunities for improvement, including failures to review behavioural incidents, and failure to monitor the effectiveness of Pro re nata (PRN) medicines, As a result, the provider could not consistently demonstrate that learning was embedded into practice or that quality improvement processes were being used to enhance people's safety, wellbeing, independence and quality of life.