Summerfield Private 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 Good. At this assessment the rating has changed to Requires improvement. Leaders and governance processes 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 62 (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.

The provider’s ethos was to create a nurturing atmosphere that enhances the life of people leading to greater happiness and a strong sense of community and belonging. This was clearly understood and implemented by staff.

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.

We received positive feedback about the management of the service from people, relatives and staff. Both registered managers were visible, approachable, and responsive and worked alongside the staff team.

Staff said they were supported in their roles. One staff member said, “Management and colleagues are a good team. They are helpful and they really give their hearts to care for the residents.”

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

All staff understood the importance of raising concerns and knew the processes to follow. Staff felt able to raise concerns and were confident these would be listened to and acted on.

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 received training in equality, diversity and inclusion. Managers promoted staff wellbeing by providing personalised support and enabling flexible working. Staff felt they were treated equally and spoke positively about their role and employment and appreciated the support they received when personal circumstances impacted on work.

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

Governance processes were not robust in identifying or addressing issues. Although action was taken to address concerns we identified during the assessment, these had not been identified through the provider's own audits. For example, medicine audits did not identify ‘as required’ medicine protocols were not in place on the electronic medicine administration record (eMAR) system, and the audit did not include creams.

Effective systems were not in place to assess, monitor and mitigate risks to people as evidenced in this report. People’s care records were not always accurate, complete and contemporaneous. For example, it was reported that an individual experienced a fall overnight and had been taken to hospital. The accident report provided no details of what had occurred or how the person was found and there was no information about the fall documented in the daily records.

Some staff were related and directly line managed by their relative, who also conducted their supervision and appraisal processes. We discussed this with the provider who agreed that any future supervision and appraisal of these staff members would be undertaken by the manager who is not related to them. This approach will help to promote fairness, transparency, and equity across the staff team.

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.

Care records showed the service worked in partnership with a range of healthcare and social care professionals. This collaborative approach ensured people’s care was responsive to their changing needs.

Systems in place to ensure continuous learning and improvement at the service were not always effective. Our assessment found shortfalls which the provider had not identified and addressed through their quality management systems.

However, the provider did respond to the issues we raised and expressed their commitment to continuous improvement. We requested and received an action plan from the provider, detailing the actions already taken and those in progress to address the issues identified during the assessment. An updated service improvement plan was also provided. One of the double rooms, which accommodated 2 people was small and narrow with limited space and privacy for 2 people. There were no ensuite facilities and 1 shared wash hand basin. We discussed with the provider the long-term use of this room as a double room. The service has some very large rooms which may be more suitable as shared accommodation. The provider agreed they would review and explore this option.