Averill House

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

Governance audits were in place, but they were not always capturing gaps in risk and care planning. Processes to streamline records to move to an electronic planning system did not always ensure information being written was the most up to date. Staff felt supported by the current registered manager after concerns had been previously been raised in a staff survey about a lack of confidence to raise concerns and a lack of personal development. The provider had since made strides to improve in the area.

This service scored 54 (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.

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.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff generally felt there had been some improvements to the management and governance since the appointment of the current registered manager. Staff told us the registered manager completed daily walk arounds of the home and attend daily flash meetings for information sharing and updates. Staff felt more supported and told us there had been multiple managers at Averill House which had impacted on their ability to work in a supportive environment. A staff survey had been completed in early 2024 where staff raised if they had concerns, they didn’t feel they would be listened and not all staff had received a one to one with their manager regarding their growth and development. We did see surgeries were being planned for staff to shared concerns and growth conversations had been planned as part of supervision sessions. Staff were satisfied improvements were being made to the management of the home.

There were governance arrangements in place to provide oversight of how Averill House was operating, however, these arrangements had not highlighted some of our findings at this assessment. The provider was in the process of streamlining care records ready for the migration to an electronic care planning system. While we found some of the streamlined care records to be more concise, some of them had been completed some time ago and they were not being reviewed alongside the current care records, so were not assured the streamlined documents up to date and reflective of people’s current needs. An audit had been completed of one streamlined care record and we found it did not highlight the choking risk assessment and lacked information on the person’s modified diet, nor did it contain any information about the use of fluid thickeners and how much thickener should be administered to prevent the person from choking. Other governance records showed improvements in overall compliance at the home, however, we found an area director audit in March 2024, had found people’s care records were not updated once people returned to the home following a stay in hospital. An action plan was put into place which recorded the manager was to have oversight and check all care plans after an individual returned from hospital, however, we found the updates had not occurred for one person whose needs had significantly changed.

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.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.