Henley House

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 good. At this assessment the rating has remained good This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Leaders promoted a shared direction and culture at the service. Leaders had a positive relationship with staff to ensure there was a learning culture and a drive for continual improvement. Leaders set a high expectation on the standard of care which should be provided. This made sure people had a high-quality experience of care. The registered manager told us, “We give good care here. We all really care, and we look after people.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff consistently told us leaders were capable and compassionate. One member of staff told us, “The manager is really kind and cares. If anything is happening outside of work, they take the time to make sure I’m ok.” Another member of staff told us, “The manager is fair. They make sure people get the right care and they treat all staff fairly.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff felt able to speak up if they had a concern. All the staff we spoke with consistently told us they would feel able to speak with the manager. One member of staff told us, “The manager is really good. I can talk to them about anything. I would definitely speak with them if I had any worries. The registered manager told us, “While I work at both the service and another home within the provider, I split my time evenly across both homes. If anything, ever happens when I’m not here, I will be over straight away.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff did not experience discrimination. We found staff were recruited safely and without discrimination. All of the staff we spoke with told us they had not observed any form of discrimination and this would not be tolerated in any form. Staff told us they had a good working relationship with the registered manager. One member of staff said, “When I first started here, I didn’t have the best start. When the registered manager found out, they supported me with my induction and they really helped me out.”

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Governance systems did not always identify short falls. While the registered manager did audits, spot checks and staff supervisions on a regular basis, these had not identified the two issues regarding medication management and consent we found during this inspection. The registered manager told us how they will improve their systems to minimise this happening again.

While incidents which occurred were largely notified to CQC, not all incidents were shared with CQC, which is required by law. The registered manager submitted these retrospectively.

Following the inspection, we received assurances from the provider improvements had been made.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Staff supported people to be part of their local community. One visiting professional told us, “The manager is approachable and know what’s going on in the home.” Leaders at the service kept up to date with changes locally and worked with local community groups to work together to provide a good quality of life for people.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

People benefitted from a strong learning culture. Leaders at the service have embraced support, advice and interventions from local partners to ensure they work within best practice principles. For example, when someone has fallen, leaders have been open, transparent and worked with partner organisations to minimise the risk happening again. The nominated individual told us, “Both I and the registered manager complete investigations following an incident. We learn from this and share the learning with staff. We put up learning posters in staff areas and share learning at team meetings.”