The Headington 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 inspection for this newly registered service. This key question has been rated 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 medicines management, infection prevention and control, safeguarding, and good governance.

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 did not always have a clear 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.

We observed a difference in how people staying for short periods were included within the service, and they did not always appear to be fully integrated into the service community. The positive, inclusive culture the service aimed to create was not consistently reflected in day‑to‑day practice. Professionals told us people living at the service temporarily were referred to by their room numbers rather than their names, indicating that staff were not always providing person centred care. We also observed this on the day. This meant people did not always receive the care standards set by the provider.

Staff were able to tell us what the aims of the service were, including providing person-centred care, listening to people’s wishes, feelings and values, and to promote a safe, positive, homely environment where people were accepted as members of the provider’s society.

Staff told us they had a supportive team, and that they felt supported to carry out their roles by management.

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 were not aware of the examples of inconsistent culture that we observed on our visits to the service, and staff appeared at times to lack coordination during busy periods.Records evidenced that staff had provided feedback about challenging workloads during mornings and mealtimes, and told us this had not been fully addressed, and needed more consistent staffing levels. They did not always ensure organisational vision was being delivered, and risks to people managed.

Leaders had the skills and knowledge to support staff, and they did so with openness and honesty. People knew who the management team were and said they were approachable. We observed the management team interacting with people and staff respectfully, in a caring way. The management team were responsive to our feedback.

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

Staff had access to a whistleblowing policy. Staff were regularly invited to team meetings, supervisions and were able to share any feedback and concerns. Staff knew who to contact if they needed to share any issues. Staff told us they felt able to speak to management and would be listened to. People and their relatives told us they felt able to speak up, and we observed evidence that this had occurred regularly.

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 ensured staff completed training on equality and diversity when they started work. The staff team worked together inclusively. Staff told us they felt supported, included in their workplace and agreed they were treated fairly and equitably.

The provider did not always have clear systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes.

The provider failed to operate checks and audits consistently and effectively to identify shortfalls. For example, the provider had failed to identify medicines errors we found during this inspection. Where checks were in place, the provider had not always acted to drive improvement. For example, an internal quality audit had identified cleanliness in the service as below standard, but actions had not been taken. The premises remained visibly unclean during our inspection. Registered manager audits had failed to identify shortfalls in relation to the fire bag held on site, such as out-dated PEEPs and Business Continuity Plan. This meant people were at increased risk of avoidable harm, as the service failed to consistently identify or act to rectify shortfalls.

There was a regular system of audits and checks undertaken by both the registered manager and the provider, which were largely focused on clinical risks rather than people’s quality of life and engagement. Actions were not always recorded as complete on audits themselves, however, were reported to the senior leadership team and held on an electronic log, with senior leaders monitoring compliance against outstanding actions. The management team had made notes to discuss audits with relevant staff in their supervision. We saw evidence of this. This meant that the service did identify lessons learned and communicate them with staff.

The provider understood their duty to collaborate and work in partnership, so services worked for people. Staff worked with healthcare professionals collaboratively to support people and supported them to access the local community.

The provider did not always focus on innovation and improvement across the organisation. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

The provider had a range of governance processes in place, and these often resulted in actions being added to the internal quality assurance and improvement plan. However, these processes did not always effectively rectify issues that affected people’s day‑to‑day experiences.