Hawthorn Court

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 inspection we rated this key question requires improvement. At this inspection the rating has changed to 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.New staff received support and training which helped them to demonstrate the provider’s values in their daily work with people. A staff member commented, “We work as a team.” A relative told us, ““[Name] is a star resident at the moment. They were involved in interviewing the new chef and presented employee of the month to some staff members.”

The provider had a proactive and positive culture of safety, based on openness and honesty. Management listened to concerns about safety and investigated and reported safety events. A staff member told us, “All incidents are reported and reviewed. Staff are very good at reporting.” Lessons were learnt to continually identify and embed good practice. People received safe care because staff learned from safety alerts and incidents. Any incidents about people's safety were discussed with staff in a timely way, with action taken to mitigate further risks.

The provider and registered manager fostered a positive culture where people felt they could speak up and their voice would be heard.The provider had a clear whistle blowing policy. Staff could raise concerns, and written information was available of how to do this. Staff meetings took place, and staff had the opportunity to share comments and give feedback. Their comments included, “I feel valued”, “Management listen”, “Meetings are a good forum for discussion” and “I would be happy to escalate any concerns.” People were informed of the complaints procedure when they started to use the service and at meetings.

The provider valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff told us they were able to ask for reasonable adjustments to be made to their working patterns for specific needs, for example to incorporate family commitments.

Improvements were needed to ensure governance was more effective and robust, including the monitoring of the quality of service provision. The provider had clear responsibilities, roles, systems of accountability and better governance. They used these to manage and deliver quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. Regular audits and checks were carried out in the main areas of the service, such as, around care records, health and safety and staff practice. Audits showed action was taken where areas of improvement were identified. However, we discussed with the manager some audits needed to be more robust and more frequent, with spot checks of the environment, staff deployment, environmental design, and medicines management.

Staff at the service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement. All professionals fed back the service worked in partnership with them. A health professional commented, “We have a monthly multi-disciplinary team meeting [MDT] with the staff and the linked GP and the staff always attend and have good input with the residents.”

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 contribute to safe, effective practice and research. There was evidence of changes that had been made to the service to make improvements and to address checks and audits outcomes and in response to people and staff feedback. External quality assurance arrangements were in place to monitor the internal governance systems.