Seven Arches 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 assessment we rated this key question good. 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.

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 processes in place to share their direction, strategies and vision. However, not all staff understood how their role supported this.

The registered manager had been absent at the service for 1 week, but senior staff had not picked up the issues we identified during this assessment. More work was needed to ensure appropriate oversight was in place at all times.

Staff we spoke with were positive about the culture at the service. They told us the registered manager was approachable and they felt comfortable to discuss any concerns and suggestions with them. Staff told us they worked well together as a team to provide good outcomes for people. A staff member said, “The management team is approachable, supportive, and committed to delivering high-quality care. I believe the home is well run, with clear communication and policies in place. Feedback from staff is welcomed and taken seriously.” Another staff member said, “I have been here 5 years, it’s a nice place to work.”

Leaders did not always have the skills, knowledge, experience and credibility to lead effectively,

Whilst we had identified shortfalls during the assessment, the registered manager and provider had responded pro-actively and provided us with an action plan on the second day of our visit. Most shortfalls had either been completed, or a plan was in place with realistic timescales for completion. The registered manager and provider recognised their internal audits and checks should have identified these issues and have started strengthening these processes.

Staff were very positive about the senior staff and told us, “Managers are very friendly and we can talk about anything.

The registered manager and the provider were very visible in the service and staff told us they were approachable.

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

People, relatives and staff all told us they could raise concerns and were confident they would be listened to. Staff were aware of whistleblowing policies and told us senior staff were approachable.

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 had received equality and diversity training and did not raise any concerns about their treatment in the workplace. They told us senior staff were supportive and responded to any reasonable adjustments when requested.

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

The providers quality assurance processes did not evidence concerns identified with infection control, risk, medicines and the environment. Other monitoring tools used also required improvement. Checks and audits such as IPC and medicine audits had not identified the shortfalls in the service.

Whilst the provider and registered manager responded proactively to the concerns found, more work was required to ensure concerns were picked up internally.

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.

People told us staff supported them to access other professionals when needed. A visiting professional said, “I do not know the management team by name, however on our visits, we are regularly greeted by senior staff, who also like an update once our visit is complete.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research.

Improvements were needed to governance records to ensure staff were identifying errors and taking appropriate action. We also identified where records used to improve oversight such as deprivation of liberty authorisations, these had not been kept up to date. As recorded in previous quality statement immediate action was taken to address shortfalls found.