Henleigh Hall

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 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 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 governance at the service. We asked the provider to put an action plan in place to make improvements to 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 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. However, it was not clear the staff team were supported effectively to understand and implement the provider’s vision. Over last 12 months there had been a change in the provider organisation who was responsible for running the care home. There had been changes to systems and processes including care planning, documentation and medicines management. Members of staff felt these changes had not been implemented or led effectively and there had been an impact on how care was delivered. A member of staff said, "The provider has only been involved for just over a year and I feel we are all just beginning to adjust.” Another member of staff told us, "Hopefully the home atmosphere will continue to improve for both the residents’ and staff team’s best interests. We want the [registered] manager to support us more and [we want to] feel appreciated."

The provider did not always have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. There was mixed feedback about leadership at the service. Some members of staff told us they were well supported but other members of staff said they had not felt supported throughout all the recent changes since the new provider took over the service. An action plan was in place following a recent quality assurance visit and the registered manager told us they felt supported by leaders in the organisation. However, the feedback from members of the staff team indicated a disconnect in the support systems in place to help people navigate and adapt to the new systems and processes which had been introduced. A member of staff told us, "I have completed a lot of training with a number of new systems put in place, but I don’t feel supported throughout all the changes." Another member of staff said, "I feel partially supported."

People did not always feel they could speak up and their voice would be heard. There were systems in place to support members of staff to speak up but everyone did not feel confident to do so. Following changes in the management team, a member of staff told us, "In the last week I feel more supported, appreciated and more understood by the deputy manager. At the moment, the provider makes it feel like it is more about the financial situation and not so much about the residents or about the staff. I hope I am wrong about this.”

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. There were no issues raised about equality, diversity or inclusion although some members of staff felt undervalued. A member of staff told us, "The registered manager and deputy have tried their hardest to continue with this but due to many system changes and a new company taking over this has been an uphill struggle for them. Carers feel undervalued and not recognised or appreciated for their hard work.”

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, or share this securely with others when appropriate. The provider had systems and processes to review and monitor quality in the service; however, the issues identified throughout the inspection had not been identified by the registered manager or the quality assurance processes in the care home. Areas we identified needed improvement included infection prevention and control, reviews of care plans and care plan inconsistencies, care not being delivered in line with care plans and temperatures for storage of medication trolleys.

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. There were working relationships with health and care partners in the local community. Information was shared appropriately to support care and improved outcomes for people.

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. The provider had actions plans in place from assurance visits and reviews. Feedback from members of staff and evidence from our reviews of care documentation indicated changes made to electronic systems had not been implemented effectively. Information had not been all transferred from the old system to new system and information was missing from people’s care plans. This created a risk about how care was planned, delivered and monitored.