Halcyon Days

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 the last inspection, we rated this key question asrequires improvement. At thisinspectionthis key question hasimprovedtogood.This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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.

Staff were positive about how the team supported people live their best lives. A staff member said, “Person centred care is probably the most important part of our role each day.”

The provider had a service action plan in place.These managed areas identified through quality checks as needing improvement.

Feedback from people and their relatives was obtained through meetings,surveys and care plan reviews. In addition, people and relatives told us the registered manager was supportive,available and approachable. Meetings were held with people,relatives and staff to share and receive information.

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.

People and relatives were positive about the service. A relative said, “They (Managers and staff team) welcome my input and the managers are far more accessible and friendly (than previous care home).”

Staff were positive about the culture and approach of the service. A staff member said, “Care is given in a person-centred way,and I would gladly recommend my home for my relative to stay if the need was to arise.”Another staff member said, “I would recommend the Home as a nice place to work and stay.”

There were systems in place to help ensure care was personalised and people had a positive experience.A staff member told us,“Both (registered and deputy) managers support the units when needed, which helps ensure good standards of care are maintained.”

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

Staff were positive about how the management team engaged with and involved them.A staff member said, “We are always asked for our feedback and any concerns we may have.”

Staff told us the registered manager was visible and approachable.

There were regular staff meetings taking place and daily ‘take ten’ catch ups.A staff survey had been carried out by the provider. Actions were implemented and recorded where needed in response to feedback.

Relatives told us they had regular contact with staff and the registered manager during visits to the home and were invited to care plan reviews where appropriate.This helped to ensure effective communication and sharing of 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.

Staff felt supported and respected by the management team. A staff member said, “We have regular supervision and support if we require it, we are also able to speak up if we have any ideas which would be helpful to the home.”

The provider had an equal opportunities policy which they adhered to. Staff employed at the service reflected different backgrounds, ages,genders and ethnicity which was a benefit for the people they supported.This was celebrated and discussed in resident meetings.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care,treatment and support in most cases. The systems needed to be used more robustly to ensure they acted on the best information about risk,performance and outcomes, and shared this securely with others when appropriate.

At our last inspection we identified there were areas that needed to be more robust in relation to governance systems.At this inspection there were governance systems to help identify and address any issues. These systems covered key areas such as care plans, health and safety, infection control,falls and medicines. Where issues were found, a plan was implemented and actions were developed to resolve them.

However, we found that some of the issues we identified as part of this inspection had not been identified through the internal quality assurance systems.These included missed care tasks, for example, nail cleaning, hair brushing, call bell lanyard cleaning or pillowcases or duvet covers needed adding to the beds people were in,pressure care and records relating to this and medicines, IPC and some environmental points noted in safe,This was an area of further development.The registered manager told us what action they had taken in response to our feedback and how they would ensure checks were more well documented to assist them in the monitoring. Additional training,meetings and supervision had also taken place following our feedback.

We found the management team responded to any complaints, feedback and requests for information or changes.

Staff were positive about the management and running of the service. A staff member said, “I feel the Service runs well,I have seen the Managers do spot checks day and night,we work as a Team and are always available to help each other out.”

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.

People and relatives told us they were supported to access health and social care professionals when needed.

The management team told us about the agencies they worked with outside of the organisation, which included health and social care agencies, and about the benefits to people and the service. This included a care providers association to access training and updates, and other health and social care teams so health care and support were accessible.For example,they worked with a discharge team for people needing short stays when transitioning from hospital and back to their own home, or a care service in their preferred area. There was positive feedback about how people were supported during this time and how the team worked with their partners.

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.

Staff told us they were kept informed and are part of working with the management to drive improvements. They said updates were shared and training provided to drive improvements and innovation.A staff member said, “Any changes to policies or legislation are kept up to date.”Another staff member said, “In terms of improvements, there is always room to continue developing consistency across all shifts and ensuring that best practice is maintained at all times. Ongoing training and continued focus on communication between staff can always help strengthen the service further. Overall,I feel it is a positive service with a strong resident focus, good multi-agency working, and a willingness from the team and management to continue improving and developing.”

The provider had developed systems to help identify any learning and improvement areas.They had plans to further improve people’s experiences.This included the registered and deputy manager spending more scheduled time with people on a weekly basis, as requested by people.

The registered manager told us about the ways they were always trying to improve people’s experience. They told us it had improved connections and created more of a family feel.They had also improved the gardens to enable people to access some areas more independently and had developed a gardening club to help people feel invested in their home.