HF Trust Hythe

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.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. The provider was previously in breach of the legal regulation in relation to the governance systems. Improvements were not found at this assessment, and the provider remained in breach of this regulation. 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.

The governance and auditing system in place had failed to identify and act on the concerns that were found during this assessment. We could not be assured that the provider had robust oversight of the service. Incomplete record keeping due to issues with connectivity to the services electronic systems meant the provider could not have effective oversight of care being delivered. There was a risk that concerns with people’s care or accidents and incidents may not be recorded or identified. This was a continued breach of regulation.

Staff were given the opportunity to raise any concerns they had or to make suggestions however, some staff felt that action was not always taken as a result of their feedback. At the time of our assessment there was not a manager registered with the Care Quality Commission. However, a number of improvements and changes had been made since the last inspection and the staff felt this had made a positive difference to people using the service.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At the time of our assessment there was not a manager registered with the Care Quality Commission. A manager was in place and was being supported by another manager covering the West Kent area. There had been a restructure of the management team following the last inspection. Deputy service managers oversaw the supported living services, and they reported in directly to the managers. People and staff spoke highly of the management team who they knew well and found approachable. A member of staff said, “‘[Name] and [Name] have done amazing things in the few months, they are amazing.”

The management team were new and were working towards understanding the issues and priorities of the service. However, the lack of consistent oversight meant that they were not always aware of some of the shortfalls in the service that were found during this assessment.

The service was split into two geographical areas with a manager for each. The managers were supported by a regional manager who was also new to the service. In one area one manager was also responsible for managing one of the provider’s residential services. The managers were supported by deputy managers who demonstrated their passion for making the necessary improvements.

Staff told us with the changes in management they now felt valued, supported and respected. Staff said, “I feel the new managers are listening, they’re great” and “I’m very confident in raising concerns.”

There were mixed views from staff regarding the effectiveness of raising their concerns or making suggestions during team meetings. Comments included, “I always voice concerns, but I’m not always listened to”, “It’s like banging your head off a brick wall” and “There is an agenda that we work through, talking about little things like money, how we are getting on as a team.”

There were mixed views from relatives about whether they felt confident to speak up about any issue. One relative told us, “People are unhappy but do not want to make a complaint.” Another relative said they had raised complaints in the past but they, “Didn’t want to rock the boat.” The provider had stopped the family forum meetings during the pandemic, and these had been booked to start again during the assessment. These meetings would give relatives the opportunities to raise any concerns or to make any suggestions.

The service valued diversity in their workforce. Staff spoke positively about their experiences at work and told us they were treated fairly. Staff told us they were asked by their line manager if they required any reasonable adjustments which were then put into practice.

Staff had been trained and followed the providers policy on diversity and inclusion. Records showed that changes had been made to enable staff to work and fulfil their role.

The provider continued not to have fully effective governance systems in place to identify and drive improvements. The service had an action plan which set out the shortfalls in the service. The management team gave us assurance that all these shortfalls identified in the action plan had been met. One of these actions was for weekly spot checks of people’s daily recording logs together with any actions that needed to be taken as a result. However, we found there were multiple omissions from people’s daily logs. For example, during a week period; 1 person had a whole day of notes missing and only 1 entry for a second day; a second person had a whole day of notes missing and another day when daily records ended at 15.35pm. There were also a number of actions that staff needed to undertake for each person to ensure their safety and wellbeing which needed to be marked as complete on the electronic system. For some people, there were over 100 actions outstanding that had not been recorded as completed. The management team were also not aware that staff working at 1 service could not always use the daily log system at another supported living service.

The management team were aware some daily log entries were missing and told us they thought it was due to staff error. There had been no analysis of the system used to record daily logs, so the provider did not realise the full extent or seriousness of the omissions. This meant the provider did not have robust and effective oversight of the care delivered.

Checks were made to ensure people’s properties remained safe a named member of care staff held responsibility for completing the health and safety checks within each house. Spot checks are completed by a member of the management team records reviewed were at different times and on different days. Records showed if any shortfalls were identified an action plan was created with the member of staff and the member of management team.

People were supported to play an active role within their local community, for example, shopping in the local community shops. Some people attended local clubs which enabled them to meet people such as dance classes.

The provider knew to contact independent advocates when people did not have family or friends who could help them to make choices and decisions.

The provider had systems and processes in place to collaborate and work in partnership with health partners, social services and the local authority contracting teams. This enabled them to share information and learning with partners and collaborate for improvement.

The provider had made a number of improvements since the last inspection, but shortfalls remained in keeping accurate records to ensure people’s safety and well-being. Gaining feedback from staff and family members to help improve the service had not been prioritised since the last inspection where concerns were identified. When issues had been raised at staff meetings, these topics had not always been carried forward to the next staff meeting to give assurance that they had been resolved or that further actions needed had been taken.

However, there had been several improvements to help ensure people received consistent care. Deputy managers worked together to help ensure that each supported living service worked to the same standards. There had been a significant reduction in the use of agency staff, so people were more familiar with staff.

Reports of accidents and incidents included if the risk was known, any immediate actions and the outcome for the person. However, as a number of daily log reports were missing there was a risk that the service would have no record of the events leading up to or after the incident in order to learn lessons.