Susan Hampshire House

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement (January 2023). At this assessment the rating remains requires improvement. The service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The service continued to be in breach of legal regulations in relation to good governance. We found the lack of a consistent manager had impacted on the service. A new acting manager and assistant were addressing the shortfalls the provider and others had identified. Some shortfalls had been highlighted several months previously, but actions were not yet complete. Staff and leaders we met were committed to the service and the people they supported. Staff were positive about recent changes to the management team and the future of the service.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Although the service had a shared vision, strategy and culture, this had been impacted by the numerous changes in leadership. The culture was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Staff aimed to ensure each person was at the centre of their support. We saw people appearing relaxed and comfortable with staff. The staff and leaders we met demonstrated a positive approach to the service and the people they supported. They respected people’s human rights and diverse needs. One staff member explained they had participated in a planning activity with colleagues and people who lived at the service. They were excited because they had worked together and identified what they wanted for the future, “Like more holidays and day trips, having a sensory room put in the TV lounge, having outside people coming in and bringing in animals, as quite a few people love animals.” There was positivity about the service’s future vision, strategy and culture.

There had been significant gaps in leadership at the service during the previous 12 months, with cover and temporary arrangements. A new management team were now in post at the service. They understood the culture and values of the service and organisation and had the skills, knowledge and integrity to lead effectively. The new management team were also aware of the issues faced by the service and had begun to develop priorities for improvement. Staff were positive about the recent changes to the management team. One staff member told us, “The manager and assistant manager are really approachable and are ready to jump in and help. They listen and want the house to succeed. I really don't think they knew what state the house was in or how bad it was, but they are turning it around.” During our visits to the service, leaders were visible and supported this assessment. They were open, honest and responsive to our feedback.

Staff did not always feel they could speak up or that their voice would be heard. Staff did not have easy access to regular supervision and support from leaders. The staff we spoke with felt unclear or unsure about speaking up about the service. They were hopeful that the new management team would be more supportive and would involve them more in the service, but time was needed for this to develop. People were encouraged to speak up individually with staff or in regular house meetings or surveys. The feedback from house meetings and surveys was positive and focused on matters which were important to the people who lived at the service.

The service valued diversity in their workforce. The provider worked towards an inclusive and fair culture by improving equality and equity for staff. For example, the provider stated they would make reasonable adjustments to meet staff member’s specific needs and would also take steps to improve and promote equal opportunities and diversity. Staff and the management team were positive about working for the organisation, and about the people they supported. Staff were hopeful that their concerns and ideas would result in positive change and improvements at the service for everyone.

The service did always not have clear and effective governance, management and accountability arrangements. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Governance and accountability processes were not used consistently to provide oversight or deliver and improve the care provided. Records of incidents, medicines and care delivery were not always completed. Sometimes these were on different forms, or not documented at all. A comprehensive audit was completed in July 2024, but not all actions arising were being addressed promptly or monitored. A follow up audit had not been completed and shortfalls we identified at the previous inspection remained. A registered manager was not in post at the time of our assessment, and there had been several changes of manager in the previous 12 months. Support was provided from within the organisation. The provider was actively engaged with the service and making improvements. A new management team had recently been appointed. They were proactive, honest and committed to making improvements. We received positive feedback about the new management team. One staff member said, “The new manager is approachable and listens. The house finally feels like somewhere you want to be a part of, and that is down to new management.” Notifications had not always been submitted to CQC. Some incidents had not been shared as required. This included notifying us of the management changes within the service or where staff had not followed a person’s treatment plan. These were submitted to CQC following our visit. The model of care at the service was not in line with all aspects of ‘Right support, right care, right culture’ guidance. This was because the service was established before the guidance was introduced. Leaders were aware of the associated risks and had put measures in place to ensure people received safe, person-centred care.

The service did not always collaborate and work in partnership with others to ensure services worked seamlessly for people. There was regular engagement with a wide range of professionals and organisations to support effective outcomes for people. However, we received mixed feedback from professionals. They told us staff did not always share information or collaborate effectively. Comments from professionals included, “There seems to be confusion between staff” and “I felt I had to constantly check and chase things.” However, there was also positive feedback from professionals. Comments included, “I have been very impressed with the level of care that each resident receives. It is very individualized, and you can see how much they all care and are willing to go above and beyond to help each resident to ensure they are healthy and happy” and “I am impressed that key workers and staff know a lot about the individual residents. This makes the care much more personalised.” People were encouraged to maintain relationships with those who were important to them and engage in activities which were meaningful and improved their quality of life. Staff helped people to access different resources and identify different ways to have new experiences and live the life they chose. The provider engaged in local forums and worked with other organisations to improve care and support for people using the service.

The service had not always focused on continuous learning, innovation and improvement in the service. The provider had not ensured there had been learning relating to all areas identified at the last inspection or in subsequent checks and audits. Necessary improvements had not always been made. However, the new management team demonstrated a desire to make improvements to the service and people’s lives. They were responsive to feedback and suggestions we made during our visit and some changes were made quickly. The management team had recently worked alongside people and staff to identify priorities and develop a plan for the future of the service.