Havengore House Residential 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 as Good. At this assessment the rating has remained Good.

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 75 (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.

The service user guide clearly outlined the service’s aims and objectives, which included freedom from discrimination, respect, and independence.

When we spoke to staff there were strong and consistent themes mentioned, these included, making the service feel like a home, ensuring that people did not feel lonely and ensuring that choice was always offered. This culture was present throughout our observations during our on-site activity.

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.

All the staff we spoke with felt supported by the management team. They felt the management team were visible, available, and modelled positive, nurturing behaviours. One staff member told us “[Home manager] is lovely, really nice, a good support anything you need is there can’t fault [them] in any way”.

Relatives of people who use the service described the management of the home in the following ways:

“Very approachable and seen around the home when I go in.”

“Easy to talk with if necessary. The Area Manager is very good.”

“Put it this way, their door is always open.”

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

The provider had a whistleblowing policy which staff had access to. Staff told us they knew how to make complaints and raise concerns. They could report concerns in 1 to 1 meetings and felt the registered manager had an open-door policy. They felt comfortable sharing any concerns with the registered manager who listened and acted on 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.

There were appropriate policies to support workforce equality and diversity. Staff told us they felt valued and were confident the registered manager and provider promoted inclusion and equity. They said they had opportunities to share ideas for improving outcomes for people within group and one to one meetings.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Managers and staff completed daily walkarounds of the building to check the standards of care. This included, gaining feedback from people and visitors, the safety and cleanliness of the environment, people’s dining experience and staff wellbeing.

Fire, gas, electrical and water safety checks were carried out in line with guidance. Audits and checks carried out on the environment and equipment used to support people with their care were effective and issues identified were resolved quickly.

There was a strong support system in place with the home manager being regularly supported by an operations manager who was based on site at the time of the inspection.

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.

Management and staff worked closely with relatives, health and social care agencies, the local authorities and CQC to drive improvement and meet people’s needs. The service met all their statutory reporting responsibilities and maintained regular communication with all relevant agencies.

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 provider had placed picture diagrams of airflow mattress pumps and operation settings as well as guidance at the base of all beds installed with one. This allowed staff to quickly identify and troubleshoot any issues with these pumps ensuring that they operated effectively and reduced the risk of pressure ulcers occurring.

The provider had also implemented innovative “Keyring Guidelines.” These were flash cards on a key ring they gave staff helpful reminders and principles to ensure safe care, for example whistleblowing procedures, MCA information, safeguarding reminders, falls do’s and dont’s etc.

Minor concerns mentioned by the inspection were immediately acted on by the provider, for example our inspection team noted two rooms where wardrobes were not securely affixed to the wall. Within 3 hours these had been secured and within 24 hours the service had updated their health and safety checks to ensure that these were routinely monitored going forward.