Hamble Heights

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.

This is the first assessment for this newly registered service. This key question has been rated Requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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.

The provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The management team did not always ensure there was a shared vision and strategy, with staff knowing their role in helping to achieve these. We found no evidence of this impacting on people.

We received mixed opinions from staff regards to the management team. Some staff lacked trust in the management team, preferring to speak to the nurses, if they had any concerns.

Results from a staff survey carried out in August 2024 highlighted that some staff felt the management team was not visible, approachable, were unsupportive, communication was poor and issues raised were not addressed.

The provider had identified there were ongoing issues regarding the culture and morale among care staff and were working to address them.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Some staff felt the management team was not visible, did not lead by example and demonstrate inclusive behaviours. The provider was in the process of addressing these concerns through staff meetings and ensuring staff had access to regular supervisions. We found no evidence of this impacting on people.

The provider was alert to examples of poor practice which may impact on the safety and quality of people’s care and support. For example, staff investigations were conducted robustly, in a timely manner, with actions taken to mitigate future risks.

In addition, the provider told us, ‘Following on from any incidents, staff will receive focused supervision so that identified learning, and lessons can be shared with the team. In addition to this, staff continue to receive informal supervisions and support from management through daily observations of staff practice as well as an open-door policy.’

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

There was a clear whistleblowing policy in place which the provider adhered to.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

We received mixed opinions from staff about their confidence in their concerns and ideas resulting in positive change to shape Hamble Heights and create a more equitable and inclusive organisation. The provider was in the process of addressing this. We found no evidence of this impacting on people.

The provider informed us, ‘All staff are expected to receive 4 supervisions per year. When the home was acquired by Welford Healthcare, it was identified that there had been a lapse in staff supervisions. Since the acquisition, management have been working with the team to ensure all staff have received a formal supervision. This has now been completed and we will continue providing regular supervisions to staff. Staff are also supported with focused supervision which may also be in the form of a group supervision to facilitate discussion and group learning.’

Staff attended team meetings to ensure they were updated on things affecting the overall service. Additional meetings took place on a regular basis as part of the service’s handover system to ensure consistency of care and support.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There were clear and effective governance, management, sustainability, and accountability arrangements in place to monitor the quality and safety of the service.

Audits were completed on a regular basis as part of monitoring the service provided. This enabled any trends to be spotted to ensure the service was meeting the requirements and needs of people being supported. Where actions were needed, these had been followed up. For example, care plans and risk assessments updated and involvement of relevant health and social care professionals.

Further improvements had been made for monitoring the quality and safety of the service. For example, daily fluid chart checks, 11am huddles / flash meetings, weekly clinical governance and risk oversight meetings, and end of month analysis using the electronic care system.

The service was open, honest, and transparent with people when things went wrong. The management team recognised their responsibilities under the duty of candour requirements and followed the service’s policies and procedures.

The service had notified CQC about any significant events at the service. We use this information to monitor the service and ensure they respond appropriately to keep people safe.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

People confirmed their needs were met by staff in partnership with relevant health and social care professionals.

We received mixed feedback from external health and social care professionals about how the service worked in partnership with them.

One health and social care professional told us they were concerned about the same issues being raised by their agency and a lack of improvements being sustained by the provider. They said they did not feel their advice was welcomed and acted on.

The head of quality and compliance told us the service was working in partnership with health and social care professionals. For example, one agency had provided training for staff in treating people who have contractures. Following this the provider had introduced two ‘contracture champions’ from the nursing staff.

Another health professional commented, “I have been visiting Hamble Heights for approx. 4 years and over this time there has been numerous changes in management. Currently they appear to be being managed in a much more stable manner with a general improvement throughout. I feel generally patients and families are happy with the care at Hamble Heights and I have seen a change in most of the staff’s demeanour and they appear happier and more professional and friendly.

We have historically been concerned around care plans and record keeping. However, we have seen a significant improvement in this but also think that there are still improvements to be made in their record keeping and communication. We have regular contact with Hamble heights and feel confident to raise any concerns we may have with them and the ability to work with them and support them with changes.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

There were processes to ensure that learning happened when things went wrong, and from examples of good practice.

Following on from any incidents, staff received focused supervision so that identified learning, and lessons could be shared with the team. In addition to this, the provider told us, ‘Staff continue to receive informal supervisions and support from management through daily observations of staff practice as well as an open-door policy.’

The provider told us, ‘Welford Healthcare has taken an innovative approach to visitor logs in the home and has implemented a ‘digital reception’ system. One area where the digital reception platform has been of importance is how it has allowed us to interact further with those relatives who may have nobody else to talk to and has given them the opportunity to speak to somebody about their feelings and emotions in relation to their loved one.'

The ‘digital reception’ system also allowed visitors to feedback their experiences, which enabled the provider to monitor trends and patterns and ensure action was taken to address concerns before they became a formal complaint.

The service had implemented a new electronic quality assurance system in the home, which meant audits and action plans allowed for greater provider level oversight, enabled the analysis of themes and trend arising and the ability to take prompt and proactive actions.