Archived: Haythorne Place

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 assessment we rated this key question requires improvement. At this assessment the rating has remained 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 previously in breach of the legal regulation in relation to governance. Improvements were found at this assessment and the service was no longer in breach of this regulation.

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 was working hard to ensure there was a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. This culture needed to be further embedded and sustained to ensure there was a continuous approach to improving care.

The provider had 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 had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. Staff felt the current management team were continuing to improve the service. One staff member said, “I feel like we are making a difference now, it’s been hard, but we are getting there.” Another staff member said, "Definitely changes for the better, more staff support direction."

People did not always feel they could speak up and that their voice would be heard. There had been improvements in how staff feedback was handled; some staff reported feeling more listened to than before. However, some still did not feel valued, and the processes in place were not yet fully effective in ensuring staff concerns were addressed.

The manager told us, and records confirmed, concerns had been raised, actioned, and lessons learned. This had been communicated to staff and relatives of the person who had raised the concern. The service had a website and open-door policy to allow people, relatives, staff, and professionals to raise feedback.

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.

Leaders had a focus on diversity and inclusion. Leaders fostered a culture of acceptance and embracing different cultural beliefs with the staff team and people using the service. Protected characteristics were understood and plans put in place to ensure there was a zero tolerance to discrimination.

The provider had clear responsibilities, roles, systems of accountability and good governance. However, these needed be further embedded, to ensure there was a continuous approach to managing and delivering good quality, sustainable care, treatment and support to show they act on the best information about risk, performance and outcomes, or share this securely with others when appropriate

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. Managers told us they continued to work with the local authority, integrated care board and fire safety teams to implement improvements of the service. However, these systems and processes needed to be embedded and sustained to ensure there was a continuous approach to improving care.

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 contributed to safe, effective practice and research.

The management team were proactive in using information from audits, complaints, incidents and safeguarding alerts to improve the service. The managers worked with staff to understand how things went wrong and involved them in finding solutions. The provider had sustained the improvements in medicine management and the provider continued to demonstrate people received their medicines as prescribed. Audits had improved to include actions taken as a result of issues identified. While we received mixed feedback from staff, overall, staff morale had improved. At the last inspection the management team had identified a poor culture developing in one house. The manager had based themselves in the house providing increased oversight and support. As a result of these actions, the issue has now been resolved and the culture within the house has improved. However, all of these systems and processes needed be embedded and sustained, to ensure there was a continuous approach to improving care.