Hawthorn Lodge Care Home

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 were inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

At our previous assessment, we identified breaches of regulation in relation to the governance of the service. At this assessment, we found the provider remained in breach of this regulation.

This service scored 50 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Although the provider had equality and diversity policies in place, these were not being consistently applied by the management and staff team. People were not always respected as an individual, who was at the centre of their support when decisions about their lives were being made. We saw the management team were open, positive and wished to improve their relationships with people, relatives and relevant health and social care partners.

The management structure had seen some recent changes; we found the new management team were responsive, supportive and welcomed feedback and constructive criticism.

Staff indicated the culture of the service was improving and they felt confident in the new management team. Where safeguarding and incidents had not previously been promptly notified to the local authority and the CQC; the management team were now undertaking review and ensuring retrospective referral. This meant lessons could be learned to continually improve care quality.

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 their workforce and organisation. The provider had recently engaged a new manager at the service, to enable the required improvements to be made. However, the concerns we found had been raised with the provider at previous inspections. The progress made towards these had not been embedded sufficiently to provide assurance that the service was safe, well-led and involving people as partners in their care.

The new management team showed an openness, commitment and drive to improve the service. The new manager showed understanding of the challenges they faced and brought with them experience of improving failing services. The management team had responded to the concerns identified at our previous assessment and had a clear plan in place to address this.

People and their relatives were largely positive about the new manager. One person said, “[Name] is amiable but it’s early days.” The majority of relatives we spoke with felt confident approaching the management team to raise their concerns.

Staff understood their responsibility to speak up if they found concerns. The provider had a clear freedom to speak up policy in place.

People did not always feel they could speak up and that their voice would be heard.

The lack of previous formal engagement with people and their relatives had been identified as an area requiring improvement by the management team. One relative spoke of their frustration at an unresolved issue with their family member’s clothing. They told us, “I’ve complained about the laundry service as a lot goes missing, despite it all being named. I saw someone walking round in [my family member’s] trousers for a week before anything was done. [My family member has] had 10-15 t-shirts disappear in the last months and it costs me a lot to keep replacing things.” The management team provided an updated schedule for meetings with people and relatives and reviewed the laundry arrangements within the service.

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.

The provider employed staff from overseas and from diverse backgrounds. The new management team were aware of the strengths of their staff team and had sought to utilise their skills by delegating specific tasks. For example, management and oversight of medicines was allocated to the new deputy manager.

The provider had a menopause policy in place, to support female staff experiencing challenges due to the menopause. This policy was shared with the whole staff team, to support a whole team approach to understanding and supporting their colleagues.

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.

We saw processes in place for monitoring the safety of the environment and equipment had improved. The management team had a service improvement plan which was rated in order of need. However, this had not led to the required improvements being made since our previous assessment.

The provider had made significant changes to the management team, who provided regular updates on their actions to the CQC and the commissioners of the service. However, the providers history of non compliance with regulations had been identified as a significant concern at previous inspections, and had not been fully addressed.

The management team were clear of their regulatory responsibility. Acknowledging the lack of statutory notifications submitted previously. They arranged to review incidents of concern and ensure these were reported to us and the local authority. The provider and management team had a service improvement plan in place, to address the previous lack of oversight and quality monitoring in place at the service. This plan required embedding to provide full assurance. We will review the actions taken at our next assessment.

The provider did not always collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The management team were working hard to improve their relationships and communication with external agencies. The management team showed a willingness to engage and improve the service. We found the management team had implemented regular handovers and communication documents. However, this information was not always used effectively to inform care planning and risk management.

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.

Themes from any incidents or complaints had not been robustly analysed by the management team to look for trends. Actions taken by the service had not always been reviewed or shared in team meetings with staff for them to embed learning and improve care outcomes for people. The new management team had plans in place to ensure auditing and oversight was a priority moving ahead. However, these processes required embedding to provide full assurances regarding driving improvements.

The management team had recognised the skills of the staff team. The provider gave staff opportunities for development and progression.