Mavern House Nursing 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 remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff spoke highly of the registered manager. Comments included, “We are getting used to [registered manager]; they are really approachable which is nice and listens to us” and “[Registered and deputy managers] are both hardworking, very approachable and very understanding of our needs and the resident’s needs. They want a happy home I think and happy staff and residents. And yes, I think they have got that here.” The deputy manager said, “Between us, we have good management styles; its real partnership working. The care team know we are a management team working side by side with them, we work and walk alongside them.”

The provider and staff sought the views of people and their families through surveys, individual conversations and reviews. Records of any action plans based on feedback received were in place in the format ‘You said, we did.’ Staff felt valued and respected by the provider and colleagues. Staff were aware of the provider values and understood how they applied to their work. Staff felt the culture at the service was enabling for people and inclusive for everyone.

Staff described the management team as “approachable” and “supportive.” Comments included “We have always had team support; I have never felt unsafe. [Management team] are great, we work as a team, we can talk to [registered manager].” The registered manager said, “My biggest achievement since being here for the home has been the building of trust with the staff team and building the trust with the nurses to allow me to support them and work with them and to be trusted. When I first started, they never came to me with issues, but now they do.”

Staff felt supported, attended regular meetings, and told us they were kept fully updated with all aspects within the service. There were daily ‘flash’ meetings and staff told us about ‘Friday emails’ where a whole team update email was sent to staff. We saw minutes of staff meetings that showed how additional information was shared with staff. However, some staff told us that if they were unable to attend any meetings, minutes were not always provided for them to read.

The registered manager told us the service actively supported staff to speak up with any concerns. Staff confirmed this and said, “If I raised concerns and it wasn’t resolved, I would go via the whistleblowing email; it's on a poster in the corridor. But I do think [registered manager] would deal with it though.” Another staff member said, “If I was worried about poor care, I would speak to [registered or deputy manager] and voice my concerns. If not resolved I would go higher up. I know how to do that.” The registered manager said, “We have posters around the home, in the staff room. It gets raised at supervisions and is covered at interview and induction. When a senior manager visits, we create space for staff to speak to them if they want to. We also do the Friday email communication, and we say in that, please do come and speak to us with any concerns.”

The service had policies and procedures that supported staff in speaking up. Policies included the topics of safeguarding and whistleblowing.

Overseas staff told us they felt welcomed and included into the team. One staff member said, “I feel part of the team here. Everyone is very friendly. They took on board that they needed to speak slowly with me at first. But both [deputy and registered manager] are very easy to speak to. They always say, ‘Yes of course, come in.’ Every time they support me, and they push me to improve. They said they will support me to get my nursing registration as well.” The registered manager said, “We have several overseas staff. We make sure they have space to go and pray if they want to and when it was Diwali, we had some Indian food, and some staff brought in their saris. The residents loved that. We also have a strong Christian community here.”

Policies and procedures supported diversity and inclusion within the service.

Staff told us the management team were visible and present within the service. The registered manager said, “I do a daily walk around and go into different rooms daily. Residents will quickly tell me if there is a problem. I spot check certain things and look at ways we can improve. We monitor people's moving and handling so that we can adapt and change as needed. We can also access support from out other homes if needed.”

Regular audits were carried out, and when actions were identified, they were added to action plans. There was clinical oversight in place with weekly clinical governance meetings and monthly quality assurance governance meetings. During our assessment, issues we raised were addressed immediately or investigated and the deputy and registered manager informed us of actions taken. We saw the management team were visible. Statutory notifications were made to the Care Quality Commission in line with regulations. Staff were aware of the need to keep people’s records safe.

People did not share any concerns about this quality statement and people's records demonstrated they had timely contact with healthcare professionals.

The service had a good relationship with the local GP service. Staff said a health professional visited the service weekly and would carry out additional reviews when needed. One staff member said, “The managing older people team come in every week, and we have a list for them to review people. They're basically our bridge for the GP's. Outside of that, we can go via the out of hours service, hospital at home service or call 999. It works well.”

The service had good relationships with health professionals who visited the service. We spoke with health professionals during the assessment. One professional told us, “It has come on in leaps and bounds here. Since [registered manager] came in, I have seen massive improvements. Generally, communication is better. [Deputy manager] is brilliant; and knows all the residents so well. It’s much more streamlined now and they have a good team. The care staff are very attentive and will also flag concerns to me.”

People’s care and support records confirmed the service made appropriate contact with a range of health and social care professionals when required and in a timely way.

Staff said there was a focus on continuous learning and improvement.

The provider and registered manager were committed to continuous learning and improvement. The deputy manager said, “The way we learn from lessons has improved. Our clinical governance oversight for example, and other reviews are now in place. We try and weave lessons learned into supervisions as well.” Systems for monitoring standards of care were embedded within practice to identify areas of improvement and lessons learned. This included regular audits and quality assurance checks. There was evidence of several changes that had been made to the service to make improvements to improve safety. Complaints were managed and outcomes used to improve the service. Records showed staff were trained and supervised appropriately.