Harmony House

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• 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

This assessment did not assess all quality statements within this key question and therefore, an overall rating has not been produced. We assessed 5 quality statement; capable, compassionate and inclusive leaders, freedom to speak up, governance and assurance, partnerships and communities and learning, improvement and innovation. Systems and processes did not always drive forward improvements. Although a range of audits and checks were carried out, these were not always effective in identifying and mitigating areas of risk. Where we found concerns, such as risk management, these had not always been identified. This showed quality assurance systems were not always effective. Where checks were delegated to other members of staff, there was no effective oversight to ensure those checks were purposeful and improved standards. A learning culture was not yet fully embedded. The provider's oversight and governance systems were not always operated effectively in assessing, monitoring and improving the quality and safety of the service provided. This was a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The registered manager and regional manager were responsive to our feedback and began to address the shortfalls identified during our assessment. Staff spoke positively of the registered manager, senior staff and clinical staff team and said they were visible and approachable. Staff told us they worked well as a team and they were committed to providing good care to people using the service. Staff described a supportive environment where they felt able to raise concerns with confidence they would be listened to. However, some staff felt supervisions and praise for what they had achieved was not always given.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Overall, staff told us they thought the home was managed well and the registered manager and senior staff team supported the staff team well. Comments included, “Things are working well and the deputy is also helpful. We can ring them at any time. What we do best here is teamwork. Carers, seniors all work together as a team” and, “They, [management], want good care to be the priority. They convey this to us well.” However, one staff member told us how they felt the management team needed to advocate for people more and gave the example of supporting people to get out of bed where they have capacity to make this decision for themselves. Most staff told us the provider’s representatives regularly spent time at the home, talking to people and staff.

The registered manager and senior staff had developed processes including staff meetings and handover meetings so that staff knew what was expected of them. We found no evidence to suggest the registered manager had acted without integrity.

Staff told us they felt able to speak up. They explained systems and processes were in place to support them to raise concerns and they had confidence these would be dealt with professionally. Staff told us the registered manager encouraged effective communication and encouraged staff to make suggestions for improving the service further through staff meetings, handover meetings and one to one supervision meetings with their line managers.

Systems and processes supported staff to speak up. We saw evidence of staff meetings, handover meetings and supervision meetings. The providers policy supported this practice.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff understood their role and responsibilities. Senior staff checked on staff practice to ensure people's care was provided safely. One senior staff member told us, “You check to see what tasks staff have completed. You check people are sat up when eating.” However, some staff told us they would like more access to one to one meetings with their line managers and to be able to access support when they had been caring for people at the end of their lives which were not always forthcoming. The registered manager did not always accept responsibility for overall management of the home. Where concerns were identified, there was a focus on the staff member who should have completed the task as opposed to understanding the cause of the concern and taking action to mitigate reoccurrence.

Although a range of checks and audits were completed, these were not always effective as they did not always identify or drive forward continuous improvement. For example, there were no clear audits to ensure the quality of information contained in people's records or checks to ensure people's modified diets were followed in line with best practice guidance. Checks to ensure people remained hydrated were not always completed and some records contained inaccurate information. Lessons had not always been learned and embedded. There had been previous choking incidence at the home and records did not always support staff to mitigate risks around choking which had not been identified by the internal quality checks. Some governance processes required further development to ensure people’s consistently received dignified care. For example, in relation to catheter care. Catheter bags were suspended above bowls and there was no instruction in people's care records on how frequently these bags should be emptied or the catheter change date. Systems and processes did not always evidence that the provider had completed checks at the home. We repeatedly asked for evidence of provider oversight but this was not provided. Environmental checks had failed to identify concerns with fire doors and window restrictors. Where the registered manager delegated checks to staff, there was limited evidence to show how those audits and checks had been quality assured.

Most people and relatives felt the home was well managed. However, some people disagreed. Comments included, "I don’t think it is well managed, there’s no communication. I think I know the manager, I’m not sure. It doesn’t seem a nice culture, staff rush around all the time" and, "I've hardly seen the manager, I don’t know about being managed well." We received mixed feedback about partnership working. While people and relatives reported people being referred to healthcare professionals where needed, relatives did not always feel like the provider worked in partnership with them and involved them in people's care. 37% of people and relatives did not feel involved with people's care plans.

Staff and leaders were open in their communication and we found no evidence to suggest they were not transparent or that they did not collaborate with relevant external professionals to enable joined up care. The registered manager told us how the home worked holistically to support people's emotional need such as a priest regularly visited the home and children from a local school visited regularly. The registered manager had worked well with a healthcare professional to explore ways to support a person with their specific diet in accordance with their cultural needs. There was also a history group and therapy animals and a care home fair where members of the community were invited.

Stakeholders report positive engagement with the home. They commented on effective partnership working across teams and services to support people to achieve good outcomes.

Processes were in place to ensure the providers duty to collaborate and work in partnership with stakeholders was effective. Digital technology was used which remotely monitored people's health and enabled healthcare professionals to better understand people's health needs in order to respond more efficiently to a decline in people's health.

Staff gave examples of where learning had taken place. For example, one staff member gave us an example of how reflection on staff practise in relation to manual handling was undertaken, to further reduce the risk of skin tears. However, there had been a previous serious choking incident at the home which triggered our assessment. Feedback from staff showed learning from this incident had not yet been fully embedded and feedback from staff was inconsistent. Staff told us they had not received any best practice training around how to support people to eat and drink safely to minimise the risk of choking. Some staff therefore had a lack of knowledge around food consistency and best practice guidance. During the inspection, we found evidence of a further choking incident whilst a person was receiving covert medicines in a way that was not prescribed which showed a lack of understanding around risks related to eating and drinking.

There was an inconsistent approach to planning people’s care. People's care plans did not always provide staff with the level of guidance they needed to manage their risks such as what 'bitesize' means for people. Accidents and incidents were recorded but overall analysis wasn't always completed. There were inconsistencies in how risk and learning from key events was shared and understood.