- Care home
Aria Court
Report from 11 March 2024 assessment
Contents
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
We found a breach of the legal regulation in relation to good governance. We found that audits did not always identify issues or record actions taken. There was not always evidence of lessons learnt following incidents and some staff did not feel that their voice was heard.
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.
We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.
Capable, compassionate and inclusive leaders
We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.
Freedom to speak up
Staff told us they have regular supervisions, daily handovers and team meetings where they can share feedback. Staff said that sometimes they feel listened to and sometimes not. One staff member said that staff rarely attend team meetings and on one unit staff don't voice opinions due to the nurse being in attendance. The staff member said how their feedback regarding people had been disregarded by senior staff and they had been laughed at and made to feel 'stupid' and disrespected. One nurse told us that they supervise staff and told us that staff 'try to feedback but they are sceptical to tell me something, think I might sabotage them'. However, other staff told us that they do feel supported by senior staff and spoke positively about the new manager. The manager told us how the marketing team and hospitality team send out annual surveys to people and their relatives.
Staff meeting minutes show that the managers report back following audits, safeguarding concerns and lessons learnt. Feedback from surveys are also shared. Staff comments are recorded. Staff read and sign the whistle-blowing policy during their induction and records are kept in their staff file. Resident meetings are held which ask for feedback and record actions taken however attendance is low. Evidence of supervisions held with staff can lack feedback from staff. One staff member raised concerns they had not been shown what to do and how to complete and review forms but there were no actions recorded or further discussion. We did not see evidence of the concerns staff told us they had reported being investigated.
Workforce equality, diversity and inclusion
Some staff reported feeling that because they were care staff that their opinions were not taken seriously despite their experience and knowledge of people.
Staff meetings are held at different times to allow different staff to attend. Meeting minutes show that Managers celebrate successes with staff like external audits. The home has awards for staff and name a member of staff 'Gem of the month' who is nominated by staff and relatives. One staff member was congratulated for winning after being nominated for her attitude and pro-activeness. There is evidence of a thorough and supportive induction process. All staff complete equality and diversity training. Rotas show that the majority of staff work 12 hour shifts and we didn't identify staff working over 48 hours a week.
Governance, management and sustainability
Staff were happy with their induction and training in preparing them for their roles. Staff said that they liked that the new manager was present in the home. In general staff said that communication was good. Staff confirmed they had secure digital access to care plans. One member of staff said 'I think one day it would be nice for each member of management to work on a unit to see how hard and what it's like.' Some staff reported that they didn't understand why some staff work on different units and some don't and said that when raised with senior management that they 'don't listen to us when we tell them where there are weaknesses and strengths'. One staff member reported being confused about the senior leader roles because they said that their titles change frequently. In relation to governance the management team told us how they are revamping their audit system, are re-doing some of the questions for the business and care home and going through a training system on how to complete effective audits and create the actions. They told us they have their own quality and compliance team, complete daily walk rounds every weekday, handover meetings every day and the regional manager checks documentation and audits on a monthly basis.
Business continuity and outbreak management plans were in place and regularly reviewed. Environmental risk assessments were in place and there were daily walk arounds, observations completed, flash meetings daily where all staff were brought together, lessons learnt documentation and clinical governance once a month. The provider had their own quality and compliance team who checked audits monthly and provided support to the manager. However, audits completed stated no actions were required, even when responses to questions were negative. Lessons Learnt records were provided however were not consistent with other documents and didn’t always state how they would be shared with all staff and when. When a relative reported serious concerns we found no evidence of incident reporting, a complaint response, an investigation or report into the incident, a record of actions taken, follow up or lessons learnt. The Dependency tool and care plans were not always up-to date with the latest information. Digital records were stored securely with protected access and staff completed data protection training and signed to say they had read and understood the data protection guidance book, confidentiality and privacy notice policies.
Partnerships and communities
We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.
Learning, improvement and innovation
The activities team told us how they have to think on their feet and try different activities depending on people's needs and likes. The chef told us that they have put on book and movie themed menus. For example we saw photos of a person eating spaghetti and meatballs in front of the film 'Lady and the Tramp'. The chef explained that there was a lot of research about engaging people with dementia in activities to encourage eating more. The Manager told us that building on end of life care pathways was a passion of theirs and they want to incorporate an in depth programme of training. They also told us 'we also have dementia champions, who are supported with additional links for training and updates on new initiatives. I am now starting to role out monthly educational topics which will see us target and focus on a specific area each month, we will display information on our staff boards, hold pop quizzes with prizes and discuss learning around the specific subjects to really hone in and this will be a feature topic for our daily meetings, at present we have identified a few topics one of which is dementia, so this will be a target for the month of August.'
There was a lack of analysis and reflection following patterns and trends. Lessons learnt meeting minutes from December 2023 highlight concerns regarding communication with family and not checking medication expiry dates which were issues we identified during our visit showing that these issues had not been addressed. Some lessons learnt documentation was handwritten and not readable. No evidence of learning from deaths was seen. However, there is lots of evidence of actions taken following incidents including additional training, referrals to other services, implementing new documentation, supervisions with staff.