Hawthorne 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. 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. A learning culture was in place but not fully embedded. At the time of our assessment, there was no registered manager in post. A manager was in post and had applied to be registered with us. They had been a registered manager at one of the provider’s other homes. Although overall we received positive feedback about the manager, some people and relatives expressed concern over effective communication and did not always feel if issues were raised, these were responded to in a timely way. 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 continued breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The manager was responsive to our feedback and began to address the shortfalls identified during our assessment with an action plan. Staff spoke positively of the manager and said they were visible and approachable. Staff described a supportive environment where they felt able to raise concerns with confidence they would be listened to.

This service scored 61 (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.

Most staff felt well supported by the management team. Six staff particularly spoke about the leadership of the new manager. Comments included: “[Manager] is there if I want her” and, “I think the new manager listens more and takes on board what people are saying and tries to find a solution. She wants to deal with the problem.” Staff told us the manager held twice weekly drop-in sessions for staff to share concerns or seek support outside staff meetings and supervision meetings. The manager explained how the provider recognised the importance of supporting staff wellbeing to improve staff retention. Staff were supported in their roles and the provider promoted positive physical, mental and financial health with access to support networks and a range of benefits.

Leaders were knowledgeable about issues and priorities for the quality of service and were able to access appropriate support from professionals to be able to deliver in their roles. The manager was currently going through the registration process to become the registered manager with us. The manager told us the provider had processes to support staff with a network of benefits and the provider valued the staff team. The manager had worked day and night shifts so they had a better understanding of the home, the people and the staff team and what challenges and opportunities there were to develop the service provided.

Staff generally felt confident to raise concerns directly with managers. Comments included: “I have got a good relationship (with managers), I have no problem speaking up", "I am confident to raise concerns. Staff told us if they did not feel they could speak with managers, then they were aware of the Speak Up Guardian who regularly visited the home and could escalate concerns on their behalf. The manager explained that following feedback from the Speak Up Guardian, they had introduced a monthly drop-in session on the electronic system for reporting and recording accidents and incidents.

Processes included regular staff meetings, daily handover, daily meetings and meetings for heads of departments. The manager had spent time working with day and night staff to foster and further develop good working relationships in the team. The manager used this opportunity to speak with staff, to get to know them and to find out what the issues were in the past and present so they could focus their efforts to improve the culture at the home. The manager told us having a consistent staff team had helped settle things down and would help to foster closer team working. The manager also had a ‘open door’ so anyone could speak with them to offer any feedback.

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 told us there was a 'flash meeting with managers at 11.00am' every day when they could raise any immediate concerns or issues that could compromise safety. Comments included, “On a daily basis we have a flash meeting which gives us the opportunity to relay back to the managers what is not working so if you are struggling you get help” and, "Every day we have flash meetings and we go to the deputy between 11 and 12 and if we have got any concerns, we let the deputy know." However, we found staff’s knowledge of people was inconsistent. Staff told us they were moved between the units within the care home. One nurse told us they had worked in 5 units across 5 days and felt this did not enable them to give consistent care. This nurse said, "I don't get to know people well." We also identified some people were moved by the management team between units which added to staff's worry about inconsistent care.

The provider had processes to monitor and review regular audits and checks. The manager had weekly meetings with clinical staff to review the risks within the home and ensure they were being appropriately and effectively managed. One nurse told us, "Every Wednesday there is a clinical governance meeting. We discuss how many falls we have had, who is on blood thinners, equipment checks, any infections or wounds on units." The director of quality and compliance showed us quality assurance tools and how those tools reviewed and improve people’s outcomes. Some of those checks included internal ‘mock inspections. However, we found, and we have reported on a number of issues that have not improved sufficiently since we identified them at our last inspection in November 2023. People’s exposure to risks continued, specifically in medicines management, environment and infection, prevention and control. A continued lack of effective reviews and quality assurance systems had not taken steps to drive improvements through effective governance and quality assurance. The above issues demonstrate a continuing breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The manager and director of quality assurance were committed to making improvements. A recent mock inspection undertaken by the provider had identified some issues and the manager had implemented additional systems and processes to assure themselves, they knew what needed improvement as a priority. Following our visit, the manager sent us an action plan stating what they intended to address straight away. On reviewing additional information sent to us, we are not confident the measures put in to place will ensure a good quality and safe service is delivered to all. For example, of the 3 'when required' medicine protocols shared with us, they were written after our on site visit and there was a lack of clarity and direction to staff to minimise risks.

Relatives told us they could visit whenever they wanted to. Relatives said if there were any changes to their family member’s health and welfare they were informed. Some relatives shared examples with us of times their relative was in other health care settings and the care was not as good as it was at Hawthorne House.

The manager was working with the ICB to ensure information about the service was shared with people and their relatives before they were discharged from hospital. The manager also explained that a new process had been implemented to ensure every relative was updated once a week about their family member’s health. Where people did not have any family, they were arranging advocates to ensure people’s voice was heard and their preferences met.

A healthcare professional told us they felt some improvements had been made at the care home, but these needed to be embedded in practice and further improvements were still needed. This included effective stock checks on medicines and ensuring staff consistently had the skills they needed in using the electronic device for medicines administration.

There were numerous processes in place that enabled managers and staff to work in partnership with stakeholders such as healthcare professionals. For example, information was shared by the manager with the ICB and local authority and ourselves (CQC). The provider and manager had worked closely with the ICB implementing a service improvement plan. The manager was aware this was ongoing and some further improvements were needed and others needing embedding and sustaining in practice. Staff referred people to mental health care professionals when their mental wellbeing deteriorated in an effort to maintain positive outcomes for people living at the home. Systems were in place to enable staff to record concerns about people’s wellbeing that needed to be discussed with the person’s GP, and overall, staff followed this process so concerns could be acted on.

Staff told us information about accidents and incidents and changes in people’s care was shared with them through meetings and daily handovers. One member of staff described how following a significant incident in the home, the manager had shared guidance with staff about how to mitigate that specific risk. The director of quality and compliance showed us systems and processes they had worked on which had not yet been fully rolled out. These new systems had been designed through learning from mock inspections and CQC’s new approach to assessment. The director of quality and compliance told us there were areas for improvement and was confident those new systems would improve the quality of care.

The director of quality and compliance explained the quality and assurance systems and processes currently in place and those due to be implemented. It was clear from this conversation, the director had a firm grasp of quality assurance, what its purpose was and how to use it. The director told us in addition to audits and checks, lessons were learnt from recent communication from CQC and the National Institute for Clinical Excellence (NICE) and other partners where practice was to be considered. We were told lessons were learnt from inspections of other homes to drive standards and share lessons with managers and staff. The director also created a tool to assess through internal mock inspections, the likelihood of scores against each CQC quality statement. This was positive, however, issues found by the providers systems 6 months ago remained unresolved relating to risk management, medicine management and a quality assurance system that was not effective. We found staff were not always clear of their responsibilities when checks were delegated to them. The manager told us they had to create additional checks to give themselves assurance of what needed improving and in some examples information was conflicting.