Archived: Harmony House

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 where a rating has been awarded. At the February 2024 assessment under the previous legal entity, although we found some issues there was not enough quality statements assessed so we could not rate. At this assessment this key question has been rated requires improvement.

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 good governance at the service.

This service scored 54 (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 shared vision, strategy and culture. This was not always based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Aspects of the culture did not promote people’s psychological wellbeing. For example, 1 person told us they experienced distress because they were told medicines errors had occurred for them and were later retracted. Other families sometimes shared personal information openly that had become known to others. The culture was such, where errors had occurred these were shared inappropriately causing further distress to some people.

Staff gave us mixed feedback. Some staff were fearful of reporting concerns because the approach taken by senior staff/management meant sensitive information would be released. Some staff said this was a problem to them so they would not raise concerns. However, other staff found the new management team supportive and not afraid to respond to emerging issues. One staff member said the new manager had made positive steps to deal with previous issues and where staff practice needed to be addressed, the manager was taking action which may not have been taken before.

Not all leaders or the provider had the skills, knowledge and experience to lead effectively, or they did not always do so with integrity, openness and honesty.

Most people knew who the manager was. We got mixed feedback about the manager’s actions that on occasions there was no change. One person described their experience at Harmony House. They said, “I’m just here to be looked after although I think I could be looked after better. I think it could be run better as well. The staff suit themselves what they do and when they do it. Even the nurse to some extent. I would definitely not recommend it. The care needs to be more consistent and timely. Despite that I feel safe as the clinical care is good.” People’s comments to us showed some people had experienced some negative experiences. A staff member told us, “I don't see progress with [registered managers name], promises are not kept. I feel I can go to the area manager and I get on with them. They would listen, but money is the problem.” Some staff had more confidence in the manager than others, citing previously issues that had not been addressed, now being dealt with.

The provider did not always foster a positive culture where people felt they could speak up and their voice would be heard.

Staff feedback was mixed. Some staff told us when they had raised issues, they felt confidentiality had not been met and they felt disappointed, saying they would be less likely to raise further issues. Other staff were complementary in sharing feedback through meetings and supervisions. It was clear all staff knew how to raise concerns and speak up but there was not a consistent response to actually do this. Some nurses told us they did not feel supported by management and felt a feeling of being overwhelmed with work. Nurse staff did not feel management always listened to them. Any changes implemented to help them were not always maintained and they said promises made were not kept to regarding staffing numbers of shift.

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.

Staff gave us examples where they had shared their personal situations with the management team. In those cases where necessary, their shift patterns or working hours were altered to help those staff. One staff member said they had a condition that made certain tasks difficult, and their work in the home was based around managing their overall health and wellbeing as well as those people they cared for.

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

A previous inspection had found a quality assurance system that was not always effective or proactive to identify, monitor and sustain improvements. Following our last assessment in February 2024 where we found a breach of legal regulations in relation to the governance of the service, we told the provider they needed to be compliant. At this assessment, we saw some audits and actions had been taken, however some issues we identified previously remained. The provider remained in breach of the regulation. Where the provider was confident of improvements through some of their checks, for example in medicine management and environmental risks, we found improvements were still needed. In some cases, quality checks when delegated to others had not identified some issues and the manager was not always aware of what was and what was not checked as part of those processes. The manager told us some checks had been delegated to staff such as nurses, however, there was no managerial oversight to ensure documents were reflective of the care and support people received. For example, we found issues with poor medicine storage and return documentation, discrepancies with the time recording of medicines, some medicines not being given at correct time intervals. Despite these issues, the providers medicines audit scored 95% for July 2025.

Improvements to fire safety had been made and some improvement works were completed, however some risks for chemicals not stored or used safely still existed despite a daily walkaround being implemented to check the safety of the home. These issues identified by us had not been known by the manager or the staff member completing the checks. We also found fire door checks were being recorded in a way the staff and manager were not aware of.

There was limited oversight to check the accuracy of what was being recorded for people’s dietary needs, and fluid totals did not match the system generated targets. None of these issues had been identified through the provider’s own audit.

Where lessons had been learnt following a recent medicines error, those actions to prevent further errors were not fully investigated, so other issues had gone unnoticed. Speaking with the area and home managers, we did recognise the work and improvements that had begun. Management were committed to continuing to strengthen the quality assurance processes. Managers were open and honest with us about the challenges they had faced, particular around the culture at the home.

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.

We saw evidence of people receiving support from a range of external services. These included the local GP, tissue viability nurses, a local pharmacist and speech and language therapy. To support a programme of activities, during our visit a singer visited and sang to people in the home. Families and important links with friends and local communities were supported.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

This inspection has identified that although some learning was taken from the last inspection, a lack of continued oversight and consideration to identifying new or emerging risks was not considered. Last time we found issues with chemical storage rooms left open. This time, although locked, some products containing potentially hazardous materials were left out in communal areas. Risk plans and people care records were improved and contained useful and detailed information, yet some daily records were not always consistently recorded which could cause confusion to staff in what to offer, such as modified diets. When we had discussions with the management about a number of these issues and that improvement action was not taken between our first and second visit, the manager said, “You never told me about that.” The providers systems need to become more embedded in day-to-day practice and become reliant on establishing and identifying potential issues through your own audits and checks. This approach would support a learning and improvement approach.