Averlea Residential 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 assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. 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.

Although improvements had been made the service remained in breach of regulations in relation to governance at the service.

This service scored 61 (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.

Staff told us they worked well together and were able to approach the provider and registered manager for advice when needed. We observed staff communicating with each other about people’s needs and their emotional well-being. Some people chose to stay in their rooms and staff checked on these people regularly to minimise the risk of isolation.

Staff meetings were held infrequently but all staff were confident they were kept up to date with anything in the service. Supervisions and appraisals were now organised regularly.

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.

Since our previous inspection senior roles had been established. These roles were well defined and understood by all staff. The registered manager told us they were considering giving seniors more responsibility for supervising staff. This would encourage professional development for staff as well as helping to ensure there were enough skilled staff to complete supervisions if the registered manager was absent from work.

The provider was visible in the service and would visit regularly, including at night. These visits were not recorded which meant opportunities for learning and driving improvement might be missed. The registered manager said they would do this in future to support learning.

People did not always feel they could speak up and that their voice would be heard.

Staff told us they were able to raise any ideas, suggestions or concerns with the registered manager. A staff survey had been circulated asking staff if they were happy with their working conditions. Responses had been positive.

There were no residents’ meetings being held. The registered manager told us they had tried this, but it had not been successful. People had been asked about their care and menus via questionnaires. However, they had not been formally asked about their quality of life. Some people told us they were bored and would like more things to do.

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.

Nobody raised any concerns about this quality statement. Staff told us they felt they were treated fairly and were able to achieve a work life balance. A staff survey asked if staff had any concerns about their working conditions and if they felt they got enough support from management. Responses had been positive. Supervision records showed staff were asked if they felt confident before being allocated additional responsibilities.

The provider did not have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes.

Although many improvements had been made since the previous inspection there remained shortfalls in the organisation of the service. Audits of Medicine Administration Records (MARs) and care plans were ineffective. They consisted of a check box but did not detail which records had been viewed. We reviewed the audits for the previous 12 months and did not identify any occasion when room for improvement had been identified. However, we had found incidents when MARs had not been signed as required and care plan information that was not up to date. Cleaning schedules did not include communal areas or deep cleans. Feedback from people had not considered their quality of life. Checks of the environment had not included checks of laundry equipment or water temperatures.

Some staff working at Averlea were related to each other. This had not been considered as a potential risk and there was no policy relating to this. Following the inspection the registered manager provided us with a draft policy. However, the scope of the policy did not cover all potential risks.

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.

External professionals told us the service worked in collaboration with them to help ensure consistent joined up care. Comments included; “One of the service users that I have been supporting with has very complex needs due to a deterioration in their dementia and their behaviour has been very challenging for the staff at Averlea. The manager was active in seeking immediate support from Adult Social Care and from the mental health team and communication during the process has been excellent. In challenging circumstances, they have continued to provide the best care possible for the resident preventing neglect and maintaining the safety of both the resident and staff."

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The registered manager told us their focus since the last inspection had been to ensure the fire safety measures were completed as required and this had been done. However, action plans to drive improvement in other areas lacked detail and time scales.

People’s quality of life was not prioritised. There were limited opportunities for people to take part in meaningful engagement or access the local community.