Hampton Grange Nursing 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

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 inspection this key question safe was rated requires improvement. At this assessment we did not assess all quality statements within this key question. The rating for this key question has remained requires improvement.

This service scored 57 (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.

Staff were clear about their roles and knew when and how to raise any concerns. They told us that the registered manager provided good leadership to the team. Staff told us they were well supported and held to account for their performance when required. A member of staff told us, “The manager is helping us how to fulfil our role. I feel supported by the provider.” Another member of staff told us, “We work as a team. I have regular supervision with a nurse or a manager.”

At our last inspection the provider's quality assurance systems and processes were not as effective as they needed to be. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Not enough improvement had been made at this inspection and the provider was still in breach of Regulation 17. There were systems in place to monitor the quality of support provided to people. People's support records were regularly reviewed. A range of regular monitoring activities took place. This included an internal medicines management audit and daily 10 at 10 meetings with senior staff. The latter were 10 minutes long meetings with heads of all departments within the service. However, improvement was needed in relation to keeping some records to ensure staff always recorded up-to-date information, and all information was passed on to people’s relatives and other professionals. The provider failed to maintain an accurate, complete and contemporaneous record in respect of each service user. This was a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We received positive feedback from other professionals working with the service. A healthcare professional told us, “I have been in to see a resident recently. During the assessment a nurse assisted at all times and was receptive to advice and guidance. Nothing concerning noted during this visit.”

During our inspection we identified that the service needed to improve in including all relevant information when submitting safeguarding referrals or statutory notifications. We raised our concerns with a social worker and a lead social worker around a safeguarding referral that lacked some crucial information. The safeguarding referral had been closed; however, the lead social worker told us that having had all information at hand, they would not have closed it down. Information provided to other professionals was not always up-to-date, accurate and properly analysed and reviewed to understand its significance. As a result, appropriate action was not always taken. This was a breach of Regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff told us that the service embraced learning culture that resulted in improvements around people’s care. A member of staff told us, “I can see improvements from the time when I started working for the service.” We noticed that the service no longer requires improvement in areas such as management of medicines or pressure ulcers. Other improvements included staffing levels and staff retention.

We saw the provider had introduced a range of additional processes to drive improvements within the service. For example, monthly clinical walkabouts resulted in improved and reduced usage of antipsychotic medicines. Another example of improvement was the use of the ‘Stop and watch’ tool. The tool was was based on a concept that in case of any concerns staff would literally ‘stop and watch’, then devise a plan in response. However, further improvements were needed to ensure no the records were kept without any gaps and all appropriate information was passed to other professionals.