Heathwood Care Home

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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

We assessed all quality statements within Well Led. The service had quality assurance and monitoring systems however, they were not always consistent in identifying shortfalls at the service. We found shortfalls in some assessments. There were some gaps in recruitment processes and training. This meant the provider was in breach of Regulation 17, Good Governance. People and their relatives told us the home was run well. Staff said they enjoyed their work and felt supported by the registered manager. Feedback from professionals highlighted collaborative working between the service, professionals and families.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff knew the aims of the service. Staff were committed to providing good quality care for people, respecting people's right to make choices and maintain their independence. Staff told us, “Choice is promoted in the home” and they, “Support people’s independence.” Staff also said, “We all work together and make sure residents are looked after to a high standard, keeping them safe.”

There were no organisational values on display in the service. However, from conversations with staff and the registered manager it was clear the team had a shared vision for the home. The service had systems such as meetings, handovers and supervision to support staff working together as a team and promoting the home’s values.

Staff knew their roles and responsibilities. Staff spoke highly of the registered manager and told us they were available, approachable and provided support to the team. Staff said the registered manager was “really supportive, helpful and good at what they are doing” and they were “always tweaking to make things work for everyone, it is very fluid.”

The registered manager was available to people, staff and visitors and had a visible presence within the home. We observed the positive relationship the registered manager had with people. Regular meetings for people were held where they were encouraged to share their views and contribute to the planning of future activities and outings. Relatives were kept informed on how their loved ones were. A relative said, “We are notified of any issues.” The registered manager supported staff in their roles, this was evident through our observations, for example providing extra support to the team at mealtimes to ensure people received their choice of meal in a timely manner.

Staff knew the process to follow to raise any concerns they had and told us they felt confident to do so. Staff said, “Any complaints they get dealt with there and then” and “Management act on everything.”

The service had feedback systems in place through meetings, questionnaires and a complaints process for people, staff and relatives. The registered manager had an open-door policy. Professionals and people’s relatives visited the service regularly. The service displayed posters which provided information on how to report any concerns. Staff had regular supervisions, and competency questionnaires were completed with staff where any areas of learning were identified.

Staff told us the registered manager promoted a “work life balance” and promoted a positive culture for the team. Staff said the (registered manager) is laying the foundation, they have an open door” and “Wellbeing is good, talked about in supervisions, any problems I can pop in and speak to (the registered manager).”

The home had a diverse workforce, and staff were supported with their individual needs, for example, staff were supported to work flexibly when required. The service had an equal opportunities policy. Overseas staff we spoke with said they felt included and part of the team. The provider had an employee recognition system in place and thanked staff for their contributions.

Staff we spoke with told us the home was well managed, they had adequate training and the opportunity to learn on the job. Staff said they enjoyed working at the service and felt well supported by both the manager and the provider. One staff member said the (registered manager) is approachable” and “as a team we have daily meetings to discuss where we can improve things and discuss any changes to people’s needs.” However, during the assessment we identified shortfalls in the governance of the service. The provider acknowledged this and told us they were purchasing and implementing a new governance system to have better oversight of the service, this included the appointment of a new Nominated Individual. The registered manager accepted there were some gaps in assessments for people and started to act on this immediately.

The service had some quality and monitoring systems. However, there were shortfalls in governance systems and not all monitoring of the service was consistent. There had recently been some improvements in how information about accidents was captured. We found gaps in some assessments for people. Some of the assessments lacked specific detail and the quality varied. The provider started to take action to address the shortfalls in this area during the assessment. The service did not have a dependency tool to support safe staffing ratios. The provider told us they were in the process of implementing a new governance package to support with this. During the assessment the provider told us an additional member of staff would be on duty daily until the dependency tool was in place. We found some staff who did not have the mandatory carers training who were providing care to people. Records we reviewed showed non care staff were working as carers at times of staff shortages. We were not assured staff providing care had the required training. The business continuity plan we saw did not show how emergency staff shortages would be mitigated. Recruitment processes lacked full information about people’s employment history and gaps were not explored. This is important so the provider can ensure potential staff are safe to work with vulnerable people. The provider had an action plan, but key start dates were missing. This meant there was no way to measure the progress and completion of actions. Some actions started during the assessment. The action plan did not identify all areas for improvement. The provider did not complete routine checks on the service at night, this is important because the provider needs to ensure people are receiving consistent and safe care at all times of the day and night. The registered manager was in regular contact with relatives, the service sought feedback about the care provided, and held events that included people, relatives and staff.

Relatives told us the service kept them up to date about any changes to people's needs and hospital appointments. One relative told us "each person has their own individuality maintained, they are treated nicely and gently, with a level of dignity They keep us up to date re hospital appointments, any falls, they let me know what is going on. “

Staff said they worked with professionals to get the best outcomes for people. A staff member said, “We work with social workers, the GP and physio’s to support people.”

The service was responsive to people’s changing needs and worked collaboratively with professionals to provide safe care for people. One professional told us "Staff are always welcoming, they engage with residents well and support them as needed. They communicate well, will action any advise or concerns and let us know. They are able to provide person centred care, follow care plans written for them to provide timely intervention to their residents."

We received positive feedback regarding staff knowledge of people, when to seek advice, making referrals and communication between staff, professionals and relatives. The registered manager was known by relatives and was approachable. The service worked in partnership with visiting professionals Relatives were involved in people’s care, kept updated of any changes and involved in decision making about their family member. This was recorded in care plans we reviewed.

Staff were encouraged to share ideas on how to develop and improve the service. Staff told us, “We can try new ideas with the [registered manager].”

The registered manager was knowledgeable about the people the service supported. The registered manager took time supporting staff to understand person centred care and the expectations around how this should be delivered. Competencies we reviewed reflected learning carried out with staff, for example what staff should do when someone falls. The service acted on advice from health professionals, embedding changes into people’s care as appropriate and adopting short term care plans for people that could be more easily monitored and reviewed. The service supported people from admission to end of life care. Supporting people’s family as well as the person at the end of life.