Halcyon Days

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

At our last inspection, we told the provider to make improvements around the governance and oversight of the service. At this assessment we found some of those improvements had been made, however our findings at this assessment demonstrated some further embedding was still required. We looked at 2 quality statements under this domain. Those were learning improvement and innovation and governance, management and sustainability. Although the providers governance systems which were used to monitor the quality and safety of people’s care had improved further improvements were required. Areas such as staff responsiveness, mealtime support, people’s choices and ensuring consistent safe care provided to people around pressure care and nutrition were reported to the registered manager. They took immediate action and although we did not find these improvement directly impacted the safety and quality of people’s care, time is required to demonstrate the improvements made are sustained.

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.

Our observations showed people seemed to know the registered manager and they knew people well. Staff told us the manager was often around the home checking on things and providing guidance. One visiting professional who worked closely with the service told us the oversight and day to day care had improved since the registered and deputy manager came into post. They said, "Since the current manager came in post things have improved within Halcyon Days. From my experience they started to engage well with training. I find that the manager has good working relationships with all at Halcyon days and all that I've spoken too speak highly of them." Staff mostly felt the registered manager was supportive and approachable. One staff member said they felt, “[We have] enough staff, enough training. We are supported by the [registered] manager all the time who comes onto the floor and checks.” We also observed throughout our visit that the registered and quality manager present around the home. They seemed to know people well who in turn seemed to know them. A relative’s view after our visit told us, “I have no worries at all. I know the manager and feel I can speak up, although I have not had any relative meetings or surveys as yet, but staff always checks we’re OK.”

Although improvements had been made there were further improvements needed. Shortfalls at this assessment, reported to the registered manager included people’s choice and independence, staff deployment, learning for staff and observations of care. Although the registered manager took immediate action, time is required to demonstrate the improvements made are sustained. Surveys completed in June 2023 showed a third of people did not feel involved in developing their care plan. The action for this was to, ‘Keep working with families,’ however, we could not see how this had been improved upon. People and relatives told us that some continued to not feel engaged with at this assessment. Governance systems were in place to monitor the service with the provider using their monitoring systems to oversee the service. The provider carried out regular visits to the service to monitor safety and compliance. Auditing was in place to identify areas for improvement. However, action plans were not always clear around how to ensure identified issues were consistently addressed. For example, in the June 2023 survey a quarter of staff felt they were not involved in the improvements for the service. The action plan did not address how understand or improve this. This did not address the improvement or why some staff continued to feel disconnected. A monthly feedback survey was available at reception. The January 2024 monthly survey showed a total response from zero staff. This was the same for December 2023. The registered manager needs to improve how they capture and monitor the views of staff working in the service. Daily walk rounds did not identify where people had been in bed in the same position and audits did not identify the recording inaccuracy. For one person we observed them on their back throughout our visit. The record said they had been repositioned twice. This was not an accurate record.

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.

Our observations and discussions showed people and staff seemed to know the registered manager, who knew people well. Staff told us the manager was often around the home checking on things and providing guidance.

Regular management walkarounds took place. Daily and weekly meetings enabled learning to be shared among staff. Observations and assessments of staff practice were recorded, and improvements taken where needed. The service had staff champions in place to promote good practice. The registered manager provided examples of organisational learning explaining how the provider had installed electronic care planning and reporting in all homes to ensure information recorded was more efficient, improved the ability to share updates and changes with care needs with the staff team and enable the management team and provider to have a greater oversight of emerging risks. Recruitment challenges in the sector led to the provider acquiring an overseas licence to sponsor care staff to work across the organisation to sustain their workforce. No other evidence of wider organisational learning to improve safety were provided. For example, significant incidents across other sites or findings from CQC or local authority assessments. Managers met frequently to discuss issues and incidents across other services, but these, or themes and trends were not routinely then shared with care staff.