Hawthorn Lodge Care 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

We have identified breaches in relation to governance. Arrangements for maintaining confidentiality of data, records and data management systems were in place but not consistently adhered to. Information was not consistently used effectively to monitor and improve the quality of care. There were indicators of poor staff culture. For example, there was lack of engagement with people. Management roles modelled the type of behaviours they wished to see in staff, but this had not positively influenced the overall culture in the home. There were governance processes in place, but they were not always effective in identifying issues. There was a clear management structure and accountability arrangements. Staff understood their role and responsibilities however some staff were not proactive regarding their individual accountability for matters that may negatively impact people. Managers accounted for the actions, behaviours, and performance of staff. There were systems to manage current and future performance of staff whilst providing support. Data or notifications were consistently submitted to external organisations as required.

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 management team shared that they were aware that improvements needed to be made on the culture of the service to make it more positive and that they shared information through team meetings to support this and foster confidence in the leadership team. The NI told us, “We lead by example. We never bring our problems into work; residents need to live in a happy environment and see people smiling.” The management team discussed promoting an open culture and staff being accountable. The management team said, “We respond to any feedback and investigate concerns. We will have those courageous conversations.”

The provider had a statement of purpose and appropriate policies in place to support a culture of equality, diversity, and inclusion. Team meetings were facilitated to provide opportunities to share information and foster team working.

Staff felt that they could speak to managers at the service and receive support when needed. The management team gave examples of treating colleagues with compassion including supporting with flexible working arrangements to support people with the well-being. The NI spoke with us about providing support to staff through changes in role. They said, “We had done a probationary period, discussed any struggles and how we can support, additional training or support they needed.”

The provider had appropriate policy and documentation in place including a flexible working policy and clear job descriptions for staff to support their understanding of roles and accountability. The manager undertook training and was supported by the senior leadership team in their learning and development. Opportunities for development, including for staff who wished to achieve promotion, were explored during supervision discussion and appraisals.

Staff did not share any concerns about being able to speak up and being listened to. One staff member said, “[Manager] is always about and very helpful.” The management team spoke about wishing to have an open and honest culture where staff were able to speak up about concerns.

The provider had an appropriate Whistleblowing policy in place to support staff to raise concerns. Staff had opportunities to highlight an issue at team meetings and in 1:1 meetings with managers.

We did not receive any concerns from staff about work-force wellbeing, diversity, and inclusion. The management team spoke about measures in place to support workforce equality, diversity, and inclusion. The NI said, “Culturally we are a diverse team and equal opportunity employer and will respect staff cultural beliefs e.g. fasting, religious requirements, we make sure they are allocated breaks and religious needs are met.”

The provider had policies and procedures in place to support workforce equality, diversity, and inclusion. All staff received training on Equality and Diversity.

We spoke with the leadership team about the governance, management, and sustainability of the home. They told us about the systems in place, sharing information appropriately with others including considering GDPR, and responding to external recommendations. The NI told us, “We ensure we do oversight checks and have systems and processes in place. [Manager] has running to do lists to check off to make sure we don’t miss anything, and tasks are diarised for me, so things aren’t dropped.” During the assessment we found that issues had been missed meaning the oversight checks outlined by the management team were not robust and embedded.

Governance and quality assurance processes did not consistently highlight areas for improvement. For example, a regular management audit included water temperature checks, but this had not identified that people could access areas where very hot water was accessible and presented a risk of harm. The home support people who were known to leave the home without staff knowledge which was unsafe for them to do. Management assessment of the safety of the environment had not identified and mitigated risks. For example, doors to the outside of the property were not adequately secured. The previous CQC inspection had identified concerns and breaches of regulation, but these concerns remained an issue with ongoing breaches of regulation identified.

People were unable to provide feedback for this quality statement. The information we reviewed regarding the collaborative working practices to support a seamless service for people were mixed. There were some positive examples and others where people’s care needs had not effectively been addressed through partnership working.

The management team provided examples of partnership working with external professionals as well as internal partners and how information was shared with partners to improve services for people. The NI said, “Health care professional relationships are really good now, we see the GP for the weekly ward round, district nurse, chiropodist, and optician. We make sure people have hearing checks, see a chiropodist once a month, and appointments aren’t missed.” They also spoke with the inspection team about developing stronger community links and encouraging relationships with family members.

Partners we asked for feedback from did not have any concerns.

We saw examples of where the provider had worked with external partners to collaborate for improvement. For example, a recent audit completed by a local authority partner. However, there were examples of when the provider had not fully responded to feedback from partners, such as concerns regarding infection prevention and control raised by the CQC, to make improvements to people’s care experience.

The management team told us about changes they had planned to include a change in electronic systems which the provider felt would support improvement at the home as it would improve oversight, although this had not been implemented at the time of the assessment. The NI said, “Our governance and systems are changing onto [system name] and will be better for me and [manager] as we can review for example accident and incidents, look for any trends, and make improvements. We are always looking at how we can enhance the service.”

We noted that improvements had been made in relation to feedback from some external bodies. However, we also found that points previously highlighted as concerns at prior CQC inspections had not been robustly responded to. This meant the improvements needed for the homes rating status to improve had not been met and ongoing breaches of regulation were found.