Maer Lane

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 inspection we rated this key question requires improvement. At this inspection the rating has remained 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 shared values which included trust, openness, and integrity which were reflected by staff and recognised by people and relatives. People and relatives found the management team to be open and supportive. However, the provider did not have a formal means to seek people’s or relative’s opinions. The registered manager told us they had a questionnaire which they were going to send out to relatives but had yet to do this. Some relatives felt they had some valuable suggestions which could be considered yet did not have to formal opportunity to present these to the management team for consideration. Relatives felt the management team was approachable, but they felt a more formal means of feedback would be useful.

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. Leaders within the provider’s organisation failed to consistently demonstrate they had the knowledge to ensure people received safe accommodation and support. For example, those directing the health and safety within the building failed to ensure the correct types of restrictors were fitted to windows or free-standing furniture required a risk assessment to ensure people were safe. Those making decisions on behalf of people failed to consistently demonstrate they were making the right conclusions following capacity assessments although some assessments followed best practice. Leaders failed to consistently demonstrate they reviewed lessons learnt from incidents. However, all those we spoke with were positive about the management team and felt engaged by them in all aspects of the care delivered. One relative told us about the registered manager and said, “They are down to earth and I can tell them anything.”

The service supported a positive culture where people felt they could speak up and their voice would be heard. People were engaged about their home and the support they received and had meetings with staff and managers where they could express what they wanted or thought in a style which met people’s individual communication needs. Staff members were aware of policies and procedures which supported their employment including the whistle blowing policy. Staff generally felt they would be supported if they ever had to raise concerns.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. People were supported by a staff team who felt valued by the provider. Staff told us they liked working at Maer Lane and felt valued with access to training when they needed it. They felt able to express themselves openly to anyone in the organisation regardless of their role. However, they felt more supported by the immediate management team in Maer Lane as they felt they didn’t see the senior management very often and had therefore not built an effective relationship of trust with them.

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. Although, the provider had a range of quality tools they used to check the quality of care provided, these had not identified some issues with the physical environment including some potential risks from free standing furniture or the incorrect provision of window restrictors. Neither had they identified issues with the missing conclusions on some capacity assessments. However, once identified they took action to minimise the potential impact to people.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement. People benefited as the management team had established good links with community-based facilities including GPs, dentists and other community-based health services.

The provider did not always focus on continuous learning, innovation and improvement within Maer Lane. They did not always actively contribute to safe, effective practice. Although the provider had systems in place to review incidents or untoward occurrences within the home, they did not have effective systems in place to review the use of PRN medicines to ensure these were appropriately given. As a result, they did not have an effective system in place to identify any learning or what could potentially be done in the future to minimise the use of such interventions. Although we did not identify any harm or issues with the use of PRN medications, the safeguards against misuse were not in place at the time of the inspection. Once raised the management team committed to introduce these reviews. In other instances, we saw details of risk or improvements were shared across the wider provider organisation with managers having open means of communication where they could share best practices.