Haythorne Place

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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 identified one breach of regulation. During our assessment of this key question, we found concerns around the governance and leadership of the service which resulted in a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below. The provider did not have sufficient oversight to monitor the quality and safety of the service and to ensure there was effective leadership in place. The service did not have an effective quality assurance system to ensure people received safe care which was person-centred.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff shared concerns about the management of the service. Staff told us they did not feel that their concerns were acted upon when these had been raised with managers. Staff told us there had been changes recently within the management of the service.

Leadership at the service had failed to ensure there was a positive culture at the service that was open and person-centred. The service was in the process of recruiting new people into the management structure after a period of managerial instability, any improvements from this will take time to embed.

The service did not have a registered manager and was in the process of recruiting into this role. Managers told us that there had been several changes in management at the service and governance processes had not been followed as intended as a result.

Organisational processes had failed to ensure that management at the service had worked effectively to ensure safe care delivery and effective governance.

Staff told us they did feel comfortable approaching managers however they did not feel that their concerns or suggestions were listened to or acted upon.

The processes in place to support staff to raise concerns had not ensured that staff felt listened to or that concerns or suggestions raised had been considered and acted upon. Managers at the service told us they had recently implemented new strategies to support staff to speak up and had plans in place to demonstrate how feedback had been used. These strategies will take time to embed at the service.

Staff told us they did not feel valued, and they did not feel their concerns or feedback were listened to.

The processes in place at the service had failed to ensure that staff feedback was used effectively or that action was taken to ensure staff felt valued.

Staff told us that care delivery was sometimes delayed or completed with less staff than required due to insufficient staffing levels.

The provider failed to implement and operate effective risk management systems and to assess, monitor, and mitigate risks to people. We found various shortfalls, for example, medicines management, infection control, staffing levels and assessing and monitoring peoples planned care and risk assessments. There was a lack of effective leadership in place to ensure that governance and auditing processes were completed accurately. The audits that were in place at the service had failed to identify concerns at the service.

People’s feedback about their involvement with care planning was inconsistent, some people told us they did not feel their feedback was listened to.

Managers told us that they were working with the local authority, integrated care board and fire safety teams to implement improvements of the service. However, these improvements were ongoing and were not embedded into the service at the time of the inspection.

The provider had agreed with the local authority to stop admitting people to the home until improvements had been made. Professionals who visit the service told us that information was not always shared consistently or in a timely manner. Some professionals raised issues about difficulties with contacting the service and about the availability of staff on site to support with professional visits. Some issues were also raised in regard to the accuracy of documented information in peoples care plans.

Processes in place at the service had failed to ensure that information recorded about people was always up to date, accurate or sufficiently detailed. This meant that when information was shared about people between services the quality of this information could not be guaranteed.

Staff told us that they did not feel listened to when raising concerns about the service. Managers told us the systems in place to gather feedback from relatives and people at the service had not been used effectively in the past.

Audits and systems had failed to identify and address issues at the service including insufficient levels of staff training, issues with the management of medicines, insufficient staffing levels and issues with infection prevention and control.