Hampton Court 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

Governance and oversight systems had improved since the last inspection. Leaders had been working with the local authority to improve the standard of care and staff reported an improved culture. Systems were in place to monitor safety and quality at the service. However, some improvements were required to ensure these systems were used effectively to identify areas for improvement.

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.

Leaders explained the services shared vision and strategy. They told us they had recently implemented new ways of working however, not all staff were happy with these changes. In response, leaders worked with staff in order to explain the reason for the changes and the positive impact the changes would have. Staff told us they felt the supported and that the culture had been improving. They told us they promoted people’s human rights by ensuring people were involved in making choices about their care and support.

Information was available and shared with staff to support them in times of crisis, including wellbeing, financial, domestic abuse and counselling contact details. Additionally, some staff were offered the opportunity to complete mental health first aid training which could be used to support both staff and people at the service. However we did not see evidence to suggest that staff had training in equality and diversity human rights. Following the inspection leaders told us training for equality and diversity human rights was covered within other training provided by the service.

The registered manager explained she was supported by an experienced nominated individual who they had worked closely with to implement new systems and processes to improve the quality of care. The registered manager told us they were working with the nominated individual and the local authority to improve the way they managed safeguarding investigations as this had been identified as requiring improvement. Staff told us the manager was approachable and responsive to their feedback.

Support systems were in place to ensure the registered manager had the required knowledge and skills to lead the service effectively.

Leaders talked openly and honestly about the culture at Hampton Court and staff told us they knew how to raise concerns and would do so if they were worried about safety or the quality of care. They told us they offered an open-door policy, and that staff were encouraged to whistle blow if they felt the need.

The service had policies in place to guide staff on their whistleblowing procedure and how to raise concerns should they feel the need. Staff were supported to do this, and guidance and support was available to leaders when responding to raised concerns.

Leaders told us they ensured staff equality and diversity was maintained through their safeguarding and HR policies and procedures.

The provider had a variety of methods in which they supported staff at the service. For example payment options were available to staff who may be struggling financially. The service also celebrated different cultural events and supported international staff including familiarisation with the local area, amenities and currencies as well as offering English reading and writing classes. The staff team were diverse, and the registered manager was respectful of the different cultures, offering flexible working systems to support staff in line with their personal circumstances.

Leaders told us that the CEO regularly visited the service, in addition to weekly visits made by the nominated individual. The registered manager told us they used audits to assess and monitor the quality of care. They described the actions they took in response to audit findings to make improvements where required.

Although audit systems were in place and being used, these were not always effective in identifying safety and quality concerns. For example, electronic medication records were updated when the pharmacy delivered new medication, however no manual count was being completed to count all the medication in the overflow room. This left the medicines management process open to error. The provider’s medication audit had not identified this concern. Care records audits had not identified some gaps in the recording of Deprivation of Liberty Safeguarding (DoLS) conditions or missing information during the staff handover process. Training systems were in place to monitor staff training compliance. These systems showed there were some gaps in staff compliance for training and we could see prompts had been sent for staff to complete their required training. A monthly report was completed by the compliance officer. This included areas such as; staff performance, peoples wellbeing, and the care environment. We found that leaders used these reports to identify actions to address concerns and drive improvement. The provider had a detailed business continuity plan in place that covered areas of what to do in an emergency. The business plan was in date and set for annual reviews.

People told us they regularly saw chiropodists, doctors and opticians when they needed to.

Leaders told us that they regularly sought support from external professionals and agencies. For example if a person was falling frequently, they would contact the GP and the occupational therapy/falls team. Leaders told us they worked with the local authority to ensure they were able to provide a consistently high standard of care in line with the local authorities’ standards.

As part of the assessment we asked the local authority for feedback about the service. We did not receive a response.

We saw that the quality team at the local authority had visited the service in March 2023 and 2024. Records showed improvement actions set by the local authority had been completed as requested.

Leaders told us that they strove to improve the service. One method described was sharing learning from incidents with other services owned by the same provider. They also told us they read and used guidance from partner agencies such as Skills for Care in order to make improvements to the service.

A trainer of the month initiative which was an incentive program to celebrate staff through an award system had been introduced at the service. A new incident management system had been introduced to improve incident oversight and safety.