The Hermitage

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 assessed 1 quality statement from this key question. We have combined the scores for this area with scores based on the rating from the previous inspection, which was good.

This service scored 75 (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.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Managers told us how they continually monitor risks to people’s health. They told us they also undertook monitoring of the service. This included health and safety checks, satisfaction surveys and medicines audits. Staff told us management would regularly observe what they are doing. Staff told us team meetings did not take place, however, issues are dealt with as they arise.

Governance processes were limited and ineffective. There was an action plan for the service and it failed to identify the lack of information and reviews in people’s care records. The action plan failed to provide an overarching view of the service as it failed it include checks such as reviewing the mealtime experience for people. A comprehensive audit for care records was an action point, but the plan failed to detail how this would be designed. Whilst a residents satisfaction survey was undertaken, the analysis of the responses was not detailed. The scores were largely positive and we could see action had been taken as a result of the responses, but no analysis was undertaken of the lower scoring items on the survey, and they were not referenced in the analysis. Regular staff meetings did not take place, this was a missed opportunity for all staff to get together to share learning from incidents and discuss best practice.

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

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.