- Care home
Banbury Heights Nursing Home
Report from 19 March 2024 assessment
Contents
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
At the last inspection, the provider had failed to ensure there were effective governance and quality assurance measures in place. At this inspection we found systems and processes were still not always effective in identifying and mitigating any concerns. We found concerns with the oversight of medicines, and health concerns. This resulted in a continued breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below.
This service scored 46 (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.
Capable, compassionate and inclusive leaders
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.
Freedom to speak up
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.
Workforce equality, diversity and inclusion
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.
Governance, management and sustainability
The provider was responsive to the feedback given on the improvements required to systems and processes to ensure effective oversight. The provider submitted actions that they would implement immediately after the assessment to straighten their internal oversight processes.
The provider had systems and processes to review and analysis data. The registered manager completed audits and the provider also completed review and audits of information. However, not all audits were effective in identifying concerns or issues. For example, the medicine audit had not identified or recognised the issues with the recording of medicine administration. Audits had not identified when blood sugar monitoring had not been completed as required and the kitchen audit had not identified out of date food. We found improvement in the monitoring of records for food and fluids, oral care and mental capacity assessments.
Partnerships and communities
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.
Learning, improvement and innovation
The provider was open and transparent throughout the inspection and was open to the feedback given. The provider told us they shared information and lessons learnt throughout the other homes within the organisation. Staff told us that although they had been asked to feedback on the service to identify improvement their views were not always actioned. One staff member said, "[registered manager] does discuss and share information, but when it comes to taking forward suggestions or implementing things, actions are lacking. " Another staff member told us they did not feel that lessons learnt or information sharing was effective.
The provider had made improvements based on the previous inspection. However, the oversight systems were still not always effective in identifying missing information.