HF Trust - Pound Lane

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 good. At this assessment the rating has changed to 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.

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 clear shared vision, strategy and culture based on transparency, equity, equality, human rights, diversity and inclusion. They did not always respond consistently to the challenges and needs of people, staff and the wider community.

Despite this, there was evidence of a shared commitment amongst staff to providing person-centred care and improving outcomes for people. Staff consistently spoke about putting people first, with one member of staff telling us, “The people we look after are getting good care. The best thing is the people we support; I have stayed because of them.” Staff generally described improvements in morale and leadership under the interim management arrangements, and one staff member told us the interim manager “has made a great difference.” Relatives were also positive about the care people received and described staff as kind, caring and committed to supporting people to live meaningful lives.

However, feedback regarding leadership, communication and support remained mixed, with some staff describing inconsistencies in supervision and management support. Although leaders had taken steps to strengthen culture, oversight and engagement during the registered manager's extended absence, these improvements were not yet consistently embedded across the service.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of the organisation or consistently demonstrate the skills, knowledge and experience required to lead effectively.

The registered manager had been absent from the service for an extended period and an interim manager was providing day-to-day leadership and oversight. Staff and relatives gave mixed feedback about leadership; however, there was evidence that leaders were visible, approachable and committed to improving the service. Staff described leaders as responsive to issues and quality improvements, with one staff member commenting that the interim manager was "quick to respond." Relatives told us concerns were generally addressed when raised. However, some staff reported inconsistencies in supervision, support and communication, and some relatives felt communication had reduced during the period of management change. Although leaders had taken steps to improve morale, oversight and service quality, these improvements were not yet consistently experienced across the service and further work was needed to embed effective leadership arrangements.

People did not always feel they could speak up and that their voice would be heard. There was evidence that staff understood how to raise concerns and felt able to escalate issues through management structures and whistleblowing processes. Staff were able to describe safeguarding and whistleblowing procedures and one staff member told us they would report concerns to a senior or manager and use the whistleblowing process if they remained worried. During the assessment, leaders responded appropriately to concerns that had been raised, including commissioning an independent review in response to a whistleblowing concern. However, feedback from staff was mixed. Whilst some staff felt listened to and supported, others described feeling unsupported following incidents and reported inconsistencies in communication and management support. This meant that although mechanisms were in place for staff to speak up, they were not always experienced consistently across the service.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider recognised the importance of valuing and supporting a diverse workforce. Staff described working within a caring and supportive team environment and spoke positively about relationships with colleagues. There was evidence that staff were encouraged to share their views through team meetings, staff surveys and wider organisational initiatives, including the provider's "Big Conversation" survey. Staff from a range of backgrounds and levels of experience worked across the service and were supported through induction, training and supervision processes. However, feedback about staff support and communication was mixed, with some staff reporting inconsistencies in supervision and management support. Whilst there was evidence of an inclusive culture in practice, further work was needed to ensure all staff consistently felt valued, listened to and supported.

Governance systems were in place to monitor the quality and safety of the service. The provider completed a range of audits and reviews, including monthly analysis of accidents, incidents, medicines errors, injuries and safeguarding concerns through various reporting systems. These reports were used to identify themes, trends, lessons learned and actions required to reduce risks and improve outcomes for people. Leaders had also developed service improvement and maintenance plans and were working with partner agencies to support ongoing improvement. However, governance processes had not always been effective in identifying and addressing issues promptly, as evidenced by gaps in record keeping, medicines management, regulatory reporting and oversight of some DoLS authorisations. Whilst leaders demonstrated a commitment to improvement and sustainability, further work was needed to ensure governance systems consistently identified risks and embedded learning across the service.

The provider worked collaboratively with people, relatives, healthcare professionals and external agencies to support positive outcomes and wellbeing. Records demonstrated appropriate involvement from health and social care professionals, including GPs, psychiatrists, neurologists, SALT, social workers and safeguarding teams, with referrals made when needs changed. A healthcare professional described the service as providing safe, person-centred care with skilled staff, effective communication and "excellent" management. People were supported to maintain relationships and access local community activities. One relative told us, "They always answer any of our questions." The provider was also working with the local authority and partner agencies to drive improvements and embed positive changes. Although some relatives felt communication reduced during the registered manager's extended absence, there was clear evidence of effective partnership working to support people's health, safety and wellbeing.

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.

Leaders demonstrated a commitment to learning and improving the service. The provider used audits, incident reviews and monthly analysis reports to identify themes, trends and opportunities for improvement, with lessons learned shared across the staff team. The provider was working collaboratively with the local authority and other partner agencies to implement service improvement plans and address areas of concern. Actions had been taken in response to identified issues, including enhanced oversight, staff training and reviews of systems and processes. However, whilst improvements were being made and leaders were responsive to feedback, some recurring concerns indicated that changes were not yet consistently embedded or sustained across all areas of the service.