Hope Valley Nursing 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 newly registered service. This key question has been rated 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 people’s safe care and treatment, staff training, person centred care and governance at this inspection.

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 clear shared vision, strategy and culture. This was because the provider’s policies and procedures in place to ensure the delivery of safe care were not always followed. For example, a lack of system to review accidents and incidents to ascertain the nature of concerns and identify patterns and trends was not in line with the providers incident reporting policy which stated such system would be in place. Failure to follow policies, and embed safe practices placed people at risk of receiving care that was not in line with expected standards.

The registered manager did not demonstrate the necessary leadership skills to ensure the service was safe and well-managed. Quality assurance processes had not been effective in identifying risks or driving improvements, and this contributed to ongoing concerns about safety and oversight.

However, at the time of our inspection, a new manager had recently taken up post and was expected to assume full responsibility for the day-to-day running of the service, with the current registered manager stepping down. Alongside this, a newly recruited senior leadership team had been established. This included a clinical lead, more senior carer posts and heads of department such as domestics and kitchen. This had the potential to improve accountability and provide more robust oversight of key risk areas going forward. While these changes were promising, they were not yet embedded at the time of our visit, and therefore we could not assess their effectiveness in practice.

Staff reflected positively on working at Hope Valley Nursing Home, and felt leaders promoted a working environment that was safe and friendly which motivated them to provide person-centred care. One staff member told us, “[Manager] has such a vision and brings positivity to the service. They are so helpful and supportive.”

Whilst some processes were in place to support people, staff and visitors to raise concerns, such as a whistleblowing policy, further improvements were required to ensure systems to support staff in speaking up were fully embedded. For example, regular staff supervisions had only just been implemented, and some staff supervisions were outstanding. Some staff shared they had raised concerns about unsafe staffing levels but felt these concerns had not been listened to.

However, we received feedback that staff, people and relatives knew how to raise concerns. One staff member told us, “[Manager] is very approachable, I definitely feel listened to.” And “The owners are all very good and if we have any concerns they will listen to them.”

There was a lack of formal structure in place to support staff from ethnic minority backgrounds. For example, staff who spoke English as an additional language did not always approach the manager directly, opting to speak with leaders who spoke their first language. Whilst communication systems were not yet fully embedded, leaders acknowledged this gap and shared plans to implement more inclusive systems to ensure all staff felt supported, heard and valued, regardless of their background. We found this had not impacted on the delivery of care and we received no concerns about discrimination during our inspection. One staff member told us, “I have never dealt with any discrimination myself, I think as a workplace we are very inclusive.” Leaders assured us any concerns about discrimination would be listened to and acted upon.

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. There was a failure to implement effective systems to oversee risk and quality at the service. For example, no audits or quality assurance checks were carried out in relation to IPC. Some audits and checks of key risk areas had not been carried out until after our inspection, including audits of accidents, incidents and wounds. We found these audits once completed, did not provide robust oversight and failed to identify and mitigate risks to people. This placed people at risk of receiving unsafe care.

While the service did engage with partner agencies, its approach was often reactive rather than proactive. The provider did not always identify issues through its own systems and instead relied on external agencies to highlight areas needing improvement. This meant that opportunities for early intervention or collaborative problem-solving were sometimes missed.

The manager was open and transparent throughout the inspection process.

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. They did not actively contribute to safe, effective practice and research.

The provider did not ensure quality assurance processes were proactive in driving improvement. Audits, where present, lacked clear ownership and timescales for action where areas for improvement were identified and findings were not systematically used to drive improvement. For example, a care plan audit had identified issues within one person’s care plan, yet the associated action plan did not include actions to address all of these areas. This placed people at risk of receiving unsafe, or unsuitable care.

In addition, the providers service improvement plan failed to acknowledge the lack of effective governance system in place to monitor the quality and safety of the service, and contained actions which were signed off as completed, yet found to remain an issue during our inspection. For example, weekly medicine audits were not in place as the action plan stated. This increased the risk of repeated issues, missed opportunities for learning, and placed people at risk of receiving unsafe care.