Hylton Grange

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

This was the first rated inspection of the service. Systems were in place to assess, monitor and improve the service, however some improvements to governance and medicines management were identified at inspection. The service promoted a positive culture which was practised and promoted by the whole of the staff team. People and staff said they were not afraid to speak up and they knew they would be listened to. There was an emphasis on learning and improving throughout the service. People, their relatives and staff were asked for their views and experiences of the service. Feedback was listened to and addressed. Staff and managers worked in partnership with visiting health and social care professionals which provided good outcomes for people. There was a capable and compassionate management team who, with staff, worked to ensure good quality care for people in partnership with external professionals. Staff told us they felt supported by the management team. The service had accessible policies and procedures that staff were aware of and kept updated with. The service demonstrated that it valued diversity in its workforce and worked towards an inclusive and fair culture by improving equality and equity for its staff.

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 and leaders shared the values and vision of the care provided in the home. Staff we spoke with explained the values of caring, passionate, teamwork which were at the centre of their day-to-day work. Most staff members said they worked as a team and they felt morale was good. Staff told us there was team working and they felt supported by colleagues and management. Most felt it was a good organisation to work for and would recommend the service as a place to work.

The policies and procedures the provider had put in place were based on providing transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and local communities. New staff received support and training which helped them to show those values in their daily work with people. The quality and vision of the service was regularly discussed with staff during a range of meetings.

Staff told us there was very good leadership in the home. Feedback from staff and the registered manager demonstrated leadership in the home was based on inclusivity and how the registered manager understood the context in which care was delivered and how that had a positive impact on the culture and values of the service. Staff told us they thought the registered manager led by example and they had the skills, knowledge and experience to manage the service. A member of staff commented, "The registered manager is very accessible if you need them, I would feel safe and confident raising any concerns."

Policies and processes showed how the registered manager and their team shared good practice amongst meetings, audits and feedback captured good examples of a positive culture where people were happy with the service. The registered manager was very visible in the home. We saw them being involved, communicating with people and staff and leading by example. The registered manager had built a strong leadership structure in the home and worked as a part of the team, being visible to people and relatives, and building good relationships with partners.

Staff were confident to raise issues with the registered manager and felt any concerns would be thoroughly investigated. They felt their views were valued and they confirmed they were listened to.

The provider had policies and systems in place, which aimed to foster a positive culture where people felt they could speak up and that their voice would be heard. There was a clear whistle blowing policy and supporting systems in place. Staff could raise concerns internally and externally and the information on how to do this was available in the service. There were engagement surveys sent to people using the service, and staff. Regular staff meetings took place. There was a complaints procedure. Staff and people said they had confidence in the management team and would not be afraid of raising any concerns.

Most staff told us they felt valued and respected in their roles, however some staff fed back they did not all feel respected by colleagues. All staff said they felt well-supported by the registered manager personally and professionally. Staff told us they were able to ask for reasonable adjustments to be made to their working patterns for specific needs, for example to incorporate family commitments or caring responsibilities.

Policies and practices were in place to help maintain a workforce in which equality, equity and exclusivity prevailed. This was largely driven by the culture and attitudes of the staff, who valued the staff team and helped to support one another on both a professional and personal level.

The service demonstrated effective processes in relation to responsibilities, roles, systems of accountability and governance. Staff and leaders knew their responsibilities around quality and safety monitoring and governance. The registered manager with staff regularly reviewed the systems and processes to determine if improvements could be made. The registered manager and senior staff could clearly explain governance systems in the service and their individual responsibilities, however there were areas of improvement regarding the management of medicines records identified at inspection as previously described. The registered manager took action to make improvements in the identified areas however, the improvements had not yet all had time to become sustained or embedded.

There were mostly effective governance systems in place, but some improvements were required to medicines management and medicines records as identified. Regular audits and checks were carried out in the main areas of the service, such as around care records, health and safety, staff practice. Some previous medicines audits had not been so effective in making improvements, as resulting action plans had identified the same areas of improvement in 3 of the provider's subsequent audits. The registered manager and the provider’s compliance department supported the management team by completing reviews of quality and safety of the service in line with regulatory requirements.

People and relatives told us the service worked well with other agencies so people could access appropriate help and support when required.

Staff understood their duty to collaborate and work in partnership. Staff and managers explained how they worked with healthcare, social care and community partners. They had good knowledge of the local services and support systems and how to access them. The registered manager told us they had a very good working relationships with community partners to ensure people's needs were met holistically. They also gave examples of some people using the service who used or supported some local charities for day care or volunteer work opportunities, with the aim of them moving to paid employment.

External professionals told us the service had developed good links with them and they provided positive feedback about working with the home.

Systems and processes were in place to enable the service to developed good links with the local community and work in partnership with other agencies to improve people's opportunities and well-being. The provider put measures in place to ensure the service worked seamlessly for people. They had the means to share information and learning with partners and collaborate for improvement. Management and people’s records included communication with partners such as healthcare professionals, social care teams and specialist services.

Staff told us there were opportunities for training and development. They felt there was a focus on learning and improving throughout the service. The service demonstrated it focused on continuous learning and improvement, and encouraged ways of delivering good outcomes and quality of life for people. Staff and leaders had a good understanding of how to make improvement happen. Leaders encouraged staff to speak up with ideas for improvement. A staff member told us, "I love working here."

The provider had clear systems in place to ensure learning and improvement was considered within audits, staff meetings and quality assurance activities. There was clear evidence of most changes that had been made to the service to address checks and audits outcomes and people,relative and staff feedback. However, some improvements to medicines management identified by the provider's audits, had not all been actioned in a timely way. Processes to ensure that learning happens when things go wrong, and from examples of good practice were well-established. The registered manager encouraged reflection and collective problem-solving. This occurred on a daily basis during staff handovers, daily 'huddle' and in staff meetings. External quality assurance arrangements were in place to monitor the internal governance and identified any potential shortfalls and monitored actions to reflect and improve the service on an ongoing basis.