Banbury Heights Nursing Home

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

The provider was no longer in breach of regulations. We found some improvements to the provider’s governance systems. However, these were not always fully effective in identifying or addressing areas of concern. There was a manager who was in the process of registering with Care Quality Commission. Staff told us they supported within their roles and worked with partner agencies well.

This service scored 64 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us the provider shared their values and ethos with them. Staff stated they enjoyed working at Banbury Heights Nursing Home. One staff member said, “I feel the management is compassionate, visible and proactive. They are always approachable.”

The provider ensured the culture was shared across the team. There was a recent meeting with the Values Team to create the behaviours to go with the values. The team created the ‘visual values’ and celebrated during a launch party. The team of Values Champions were now in a process of instilling the agreed values into the day-to-day operations.

Staff were positive about the management team. We asked staff if they received feedback, whether they felt included and treated with fairness. One staff member said, “Yes, they do (feedback) for example, they are choosing employees of month, during meeting appreciation for staff.” Another staff member said, “I think the management understands the challenges and the needs of the people and we usually discuss with the manager during daily 11am meeting”

When staff were asked to feedback on the service, records did not evidence what concerns were raised or what action was completed by the provider. However, the provider had various schemes in place to recognise the staff. For example, employee of the month, surveys and culture workshops.

Staff knew how to speak up and told us when they did action had been taken. One staff member said, “I have raised many concerns about the things at work and I have received feedback from the manager, and I noticed the actions in place.”

The provider had a whistleblowing policy in place as well as other ways of reporting safeguarding or speaking up concerns.

Staff told us the provider supported their individual circumstances. One staff member said, “I do believe management and seniors are very approachable and caring, always support me with caring responsibilities and working flexibly.” Another staff member described management as ‘proactive, visible, compassionate and inclusive’.

People were supported by a diverse team of staff, and we observed people at times queried what a staff member was saying to them, however, usually, if a staff member repeated their statement two or three times it appeared the person did eventually comprehend.

Since the last inspection the home manager had left and the provider’s training manager was in the process of registering with Care Quality Commission until another, permanent manager was appointed. The current manager was open, honest and acknowledged the challenges they had. They told us they still needed to make a number of improvements, for example, to aid the handover process, and ensuring all documentation was in the right place. The service was being supported by one of the provider sister home’s managers.

The provider’s systems and processes had not identified or mitigated the concerns we found during the assessment. For example, when people’s care plans did not contain sufficient information including where there were risks to people, when medicines records were not fully in place or completed, and when trends and patterns had not reviewed which staff were present or if injuries had all been recorded. We also found some of the audits were not always fully effective, for example, the provider’s cleanliness audit and fire safety audit did not identify the concerns we observed during our visit.

People benefitted from the provider who was proactively involved and part of the steering group working on the Oxfordshire Trusted Assessor Service Agreement and Memorandum of Understanding. This meant if people were assessed as ready for admission to the service, they would be assessed promptly by a trained assessor avoiding any unnecessary delays. People were supported by a diverse team of staff, and we observed people at times queried what a staff member was saying to them, however, usually, if a staff member repeated their statement two or three times it appeared the person did eventually comprehend.

Staff did not always have the information on any conditions specified under people’s deprivation of liberty safeguards. The manager had identified issues in relation to communication with partner agencies but was in the process of putting systems in place to address this.

Although we received positive feedback from some partner agencies, these had been requested by the provider and shared with us. For example, another provider had sent a letter stating the nominated individual was supportive within their role as chairman in the local care home association.

Systems and processes to gain feedback required embedding into practice to ensure it was effective in identifying any concerns or actions required. We found within the staff survey shared with CQC, there were no details recorded of the issues raised or action taken and we did not receive any evidence of relative surveys being completed or actioned.

Staff told us the management team listened to their views and suggestion about improvements. One staff member said, “If I have any concerns, I am happy to speak with Banbury Heights team, my management is very helpful, and I can speak freely, I will get the feedback as well. The manager gives the correct feedback, if I need any improvement, they inform me also if I done anything good, they are giving the appreciation as well.” However staff told us the implementation of actions to improve had been somewhat hindered by the change in the home’s management which brought further changes.

The incident analysis completed by the manager did not evidence that person centred lessons learnt were completed to mitigate further reoccurrence. For example, when a person had an incident in July 2024 where property was damaged the action included “appropriate de-escalation, distraction, retreat and return technique”. However, the lessons learnt did not include; how this action had been implemented, shared with the staff team or any details on improvements to be made. This meant there was not a meaningful or timely outcome to positively impact people. The incident analysis documents from July 2024, August 2024 and September 2024 were shared with inspectors in October 2024. However, none of these documents had been signed off by the manager. This meant systems and processes were not consistently followed.