Cheverells Care 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.

The service was in breach of legal regulation in relation to good governance.

This service scored 54 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. This was due to high staff turnover, which had adversely affected the direction and culture of the service. The provider had not conducted regular staff feedback sessions or meetings, which further hindered efforts to improve the service’s direction and culture. Staff feedback was mixed, for example, one staff member told us, “The homeowners are approachable and lovely”. Conversely, another staff member told us, “Everyone is looking for new jobs”.

However, the atmosphere during our inspection was warm and friendly, staff were attentive to people. The deputy manager was visible and worked closely with the staff team to support the home.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

There had been some recent changes in the management structure at the service to support better service delivery. The deputy manager and provider worked closely together to run the service, they had been reflective and had made some changes to improve the quality of the service delivered. However, they had not identified all of the shortfalls we found at this inspection to drive improvement in all areas and ensure compliance with the regulations. For example, the registered manager and deputy had failed to ensure a notifiable injury event had been reported to the Commission as required. This demonstrated a lack of effective oversight and governance in ensuring statutory reporting duties were met.

People and relatives were positive about the management team and felt they were approachable and responsive. A relative told us, “If I had any problems I would go to the owner. The owner is around which is reassuring.”

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

Improvements were required to ensure there was a culture of listening and learning from staff experiences. The lack of staff meetings meant staff who preferred not to speak in an individual supervision had limited opportunity to provide their feedback in a group forum about the service.

Although staff told us, “I know how to whistle blow”, we received mixed feedback from staff in relation to feeling like their concerns were acted on. Some staff gave examples of work-related issues they had raised and told us they did not feel these had been addressed to their satisfaction. However, other staff members gave an example of when they had shared concerns with the management team, and these were addressed.

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.

The management team were committed to promoting inclusive policies and practices. Staff did not note any concerns in this area. The service promoted an inclusive and fair culture, and all staff we spoke with told us they were treated equally and were happy to work as a team. One staff member told us, “We care, we look after and protect our residents, we are like a family”. Staff had received training in equality and diversity.

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

The registered manager, who was also the nominated individual, had delegated some checks to other staff members. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We found these delegated checks were not always effective in identifying where improvements were needed. For example, infection prevention and control checks had not identified the issues we found. People were placed at risk because some quality audits did not identify or address concerns with medicines, infection, prevention and control and environmental safety.

Although some internal audits were conducted, they did not identify issues observed during inspection, raising concerns about the effectiveness of governance and oversight processes.

There was no effective system in place to audit staff employment records to ensure they contained all the information required. We spoke to the registered manager about the importance of checking both new and long- term staff skills, to ensure practices reflected safe and best practice.

The lack of oversight by the registered manager meant governance of the service needed improvement.

The provider understood their duty to collaborate and work in partnership. They shared information and learning with partners and collaborated for improvement. We saw evidence of effective partnership working with external professionals, and we saw evidence of effective information sharing and collaboration. We received positive feedback from partners who worked with the service. People were encouraged to maintain relationships with their family and friends, for example one person at the time of inspection was being picked up by a relative for a trip to the theatre.

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 and effective practice. Some areas of improvement had not been identified through the management checks, audits or processes. These audits were not always effective in highlighting shortfalls and driving improvements at the service. Although improvements had been made during our inspection visits, further improvement was needed to ensure the service had embedded a sufficient governance system which identifies shortfalls of safe care delivery and treatment.

Whilst the registered manager had not identified areas for improvement we found during our assessment, they were responsive when we informed them. This included attending to maintenance issues such as a faulty fire door and arranging for agency staff to cover shifts.