Seventrees 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.

This is the first assessment for this newly registered service. This key question has been rated 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 governance at the service.

This service scored 50 (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.

We received mixed feedback from staff about the overall culture and leadership. Some staff told us they felt and valued, however others felt there was not always a culture where staff were respected or listened to.

We observed staff interactions towards people to be warm and caring, however we found improvements needed to be made to the culture regarding providing truly stimulating, meaningful activities, to promote and integrate people's individual interests, hobbies and their place within the community, into their lives.

Staff understood the values and objectives of the service. Staff understood people’s equality and diversity, and they prioritised compassionate care.

The provider demonstrated they were keen to listen to feedback from the assessment and were focussed on improving the service. They told us how they made changes to the leadership and management team, as well as improvements to the physical environment, such as replacing flooring throughout. They were open to concerns raised during the inspection, took action to address these and told us they were determined to improve the culture.

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

The provider did not have a registered manager in post. Leaders were not always knowledgeable about, or implemented solutions to, issues and priorities to improve the service. For example, not all leaders demonstrated knowledge and awareness around key subjects such as the accessible information standard, and the risk of closed cultures.

Although the provider was aware of some operational issues, they did not always identify and take effective action to address examples of poor culture which affected the quality of people’s care. For example, they had not identified and addressed the lack of meaningful and stimulating activities for people on site, until we highlighted them during the inspection.

We received mixed feedback from staff about leaders. Some staff told us the provider did not always lead by example and were not always visible in the service. However, others said the provider was always available to contact and was more present since the manager left. During the inspection we observed people knew the provider and appeared comfortable and relaxed with them.

Throughout the inspection, the provider was open, honest, and acknowledged, when highlighted, where improvements were needed.

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

Although people living at the home had the opportunity to speak up and the provider was well known and had provided families the opportunities to meet, some relatives told us they felt they did not always feel confident that their feedback was consistently acknowledged, listened to or acted upon.

Staff gave mixed feedback about feeling able to speak up, with some giving examples of when they felt were listened to, and others giving examples where they felt they were not. There were some formal opportunities for staff to speak up, with records showing they received regular supervision, and there were policies to support this, such as a whistleblowing policy.

Staff and relatives’ meetings were not always regularly held, however the provider told us they provided informal opportunities for feedback, and they would be reintroducing meetings to further improve communication.

However, the provider gave us some examples of where they had responded to, and supported, staff and relatives when they spoke up, for example to replace the kitchen.

The provider did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. They valued diversity in their workforce.

The provider took action to amend the pattern of staff shifts following a review of residents’ needs. The aim was to provide people with more consistent, safe care from a balanced staff team who knew them well, as well as providing a more even approach to shift patterns for staff. However, despite the provider consulting with staff, some staff told us they felt the outcome of this process was not fair or equitable and did not meet their needs.

There was a diverse workforce, this was welcomed and valued by the provider. They gave us examples of how they supported staff to have flexible working arrangements and reasonable adjustments to meet staff needs, while balancing the needs of the service.

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

The provider did not have a registered manager in post. This meant the provider did not always have effective oversight to ensure risks were well managed and people were protected from harm. Issues were not always identified effectively and addressed in a timely manner. For example, leaders had not always considered environmental risks, including risk from asbestos, and they were unaware the actions from the legionella risk assessment were not completed.

Some quality audits were completed. However, these were not always effective as concerns found during our assessment were not identified. For example, they did not identify all staff had not completed fire evacuation training, the risk of contamination from food stored in the laundry, and the failure to notify CQC of 1 person’s DoLS authorisation. However, when we highlighted this to the provider, they submitted the notification.

The provider told us they did not have a process for oversight of audits, meaning they could not be assured of their effectiveness. For example, the monthly health and safety audit did not identify the risk to people from hot pipes or surfaces, and the fire audit did not identify the actions from the fire risk assessment were not completed.

Health and safety checklists were completed, however, oversight was not always effective. For example, when issues were identified, action was not always taken to keep people safe, such as when the water temperatures were recorded as presenting a scalding risk to people.

The principles of Right Support, Right Care, Right Culture were not consistently reflected in practice or the systems used to monitor performance. The provider did not always enable people to live fulfilling lives with opportunities for independence, choice, and control.

Governance processes failed to identify people were not consistently offered meaningful activities and did not identify people were not having their communication needs met in line with their care plans.

The provider did not always ensure policies were adhered to. For example, the falls prevention policy stated risk assessments should be completed for all windows, and restrictors were in place to prevent windows from fully opening. However, not all windows had restrictions on them and the provider told us they did not have the risk assessments.

However, there were examples of where leaders had some systems and processes to support quality oversight. For example, the provider told us how they conducted checks of staff at night time.

The provider told us they had a plan to recruit a new manager, they begun to identify and assess some environmental risks, and they started to put systems and processes to monitor when actions needed to be completed.

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.

The provider and staff worked with various health and social care professionals to ensure people received the support they needed.

Visiting professionals told us they knew the staff, and the staff knew people well. They said these positive relationships helped communication between staff and other professionals. This meant referrals were made effectively and helped to improve people’s health and wellbeing.

People were supported to maintain contact with people who were important to them. Relatives confirmed they could visit without restriction.

However, some relatives told us because the provider had no transport of its own, and public transport was not always reliable or suitable, they sometimes had to take people to appointments.

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 provider did not always have systems and processes to identify when improvements needed to happen. Quality assurance systems were not always in place or effectively overseen by the provider. For example, their medicines audits did not identify the concerns we found during the inspection, such as 1 person’s known medicine sensitivity was not always recorded across their documentation.

The provider told us how they encourage staff to speak up with ideas for improvement and innovation, however there was limited evidence of this, and some staff told us they felt ideas they suggested had not always been listened to. There was not always a strong sense of trust between staff and leadership. However, there were some examples where staff were listened to, for example where additional staff worked at weekends.

The provider was keen to demonstrate they were committed to continuous learning and improvement. They demonstrated an openness, integrity and a willing to learn from our feedback and acted where concerns were identified. However, our findings at this assessment indicated they had not always been effective in identifying and addressing areas which needed improvement, and learning was, at times, reactive, rather than proactive. For example, where staff did not have an appropriate level of legionella training, the provider arranged this following the inspection, after we highlighted it.

The provider was transparent about the journey they had been on since they took over. This included not currently having a registered manager, introducing a new electronic care planning system and making improvements to the physical environment. They had an improvement plan to continue improvements.