Hyne Town 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

Since the last inspection the service had a new registered manager who had registered with the commission in February 2024. Staff told us the service was well managed and the registered manager was approachable and supportive. However, whilst staff told us and we saw improvements had been made in some areas, the service continues to be requires improvement and we identified 3 breaches of regulation. A range of audits were undertaken as part of a quality assurance process including systems like daily walkarounds; however, these had not identified or addressed the issues of concern we found on our visit relating to the safety of the environment, medicines management, and the MCA. The service had a whistleblowing policy in place accessible to staff to support them to report concerns. Staff told us they were supported by the management team and felt confident to raise any concerns. People and relatives told us healthcare professionals were contacted by the service, were involved in their care and visited regularly.

This service scored 57 (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.

Staff told us the service was well managed and the registered manager was approachable and supportive. Staff told us since the registered manager had taken over the service, they had made many improvements including increasing activities for people and working alongside staff, leading by example. The registered manager was new in post and was developing their experience and skills. Whilst the registered manager was able to explain how to lead the service and deliver care effectively, there were gaps in their knowledge and we had identified concerns, such as maintaining a safe environment, medicines, and the processes in place in relation to the MCA and DoLS.

Since the last inspection the service had a new registered manager who had registered with the commission in February 2024. The registered manager was supported day to day by two deputy managers. The provider had systems in place to ensure leaders were supported in their roles. The senior management team completed frequent checks and audits at the service to ensure the service was running safely, and in line with provider expectations. However, oversight by the senior management team had failed to support the registered manager to identify and address the concerns we found at this assessment.

Staff felt the manager was available and approachable and they could raise any issues or worries they may have. Staff told us they were supported by the management team and felt confident to raise any concerns.

The service had a whistleblowing policy in place accessible to staff to support them to report concerns. Staff were also encouraged to raise concerns anonymously if they wished, and had access to a comments box in the reception area to do so. Staff were supported with regular staff meetings and supervisions. The registered manager worked in an open and transparent way when incidents occurred at the service in line with their responsibilities under the duty of candour and records confirmed this.

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.

The management and staff structure provided clear lines of accountability and responsibility, which helped ensure staff, at the right level, made decisions about the day-to-day running of the service. The registered manager was aware of their responsibilities in relation to duty of candour, that is their duty to be honest and open, about any accident or incident that had caused, or placed a person at risk of harm. The registered manager described how they shared information with external agencies such as healthcare professionals when things had gone wrong as well as liaising with families where appropriate to do so. People's personal records were kept secure and confidential. Staff understood the need to respect people's privacy. The registered manager said that regular handover meetings between shifts helped to ensure essential information about people's care needs was shared within the staff team and/or escalated if needed. The provider had up to date policies, procedures, and a governance system in place to help ensure their philosophy, objectives and values were embedded into staff practice. The registered and deputy managers carried out a regular programme of audits to assess all aspects of the safety and quality of the service. In addition, the providers internal quality team undertook independent audits of the service and produced action plans. However, we found the providers governance systems these were not always effective in identifying concerns and driving improvements.

Governance processes were not effective in keeping people safe and protecting people's rights. This meant they did not drive improvement and identify the issues we found at this assessment. Issues included concerns with the management of risk, medicines, MCA, DoLS, and the environment. For example, staff consistently documented discrepancies in the number of medicines held by the service, but failed to take any action to identify what was going wrong. Care plans and bedrails audits failed to identify that risk assessments had not been undertaken for the use of bedrails. Environmental audits had not identified concerns we found with window restrictions or that that these audits did not extend to the two other properties registered as part of this location. Although the provider had in place a set of policies and procedures, these were not always being followed by staff. For example, staff did consistently apply the policy in relation to MCA and DoLS. The failure to follow these policies risked compromising people's rights. Systems and processes to monitor the service were not effective in ensuring compliance with the regulations. This was a continued breach of regulation.

People and relatives told us healthcare professionals were contacted by the service, were involved in their care and visited regularly. People were encouraged to maintain relationships; visitors were welcome in the home.

Staff understood when people needed input from healthcare professionals and had appropriately arranged for people to be seen when required.

The registered manager had developed good relationships with the local GP, district nurses and health professionals. Guidance from health professionals was included in people’s care plans for staff to follow.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.