Alison 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

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 inadequate. At this assessment the rating has changed to 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.

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 updated their statement of purpose at the time of the assessment and demonstrated that they now had a clear vision of the future and direction of the service.
The management team spoke openly about the vision and culture of the service and fostered an environment where people felt included. The deputy manager said, “I don't think I'm biased in saying that it feels great to be involved in creating the kind of care home that is right for these young people…” A staff member spoke positively about the culture of the service and said, “I chose to work here and I continue to choose to work here.”

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.
The provider and management team had a clear commitment to providing person centred care and valuing staff and young people who lived at the home.
Staff said the management team were approachable, inclusive and supportive. Staff comments included, “[The registered manager] is approachable and I enjoy working with her. I feel listened to…”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.
There were systems and processes in place to encourage and respond to feedback from young people using the service, staff and external stakeholders. We saw examples how these systems had been operated effectively to gather feedback and make changes to the delivery of care as a result.
Formal and recorded opportunities for staff to speak up included staff surveys, team meetings and supervisions. The provider had up-to-date whistleblowing policies and procedures which were in line with current guidance.

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 had access to equality policies and training to help them understand diversity, protected characteristics, bullying and harassment.
There was a formal recruitment process in place to guide equitable and fair recruitment and selection procedures. The deputy manager said, “You want a bunch of different people with different life experiences and different ages etc. It gives young people so much choice about where they want to go and how to meet their needs through different people.”

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.
At the last assessment in June 2023 we identified the provider did not operate effective systems to routinely monitor incident reporting systems and safety incidents and they did not effectively monitor areas of improvement or learn and mitigate future risks. We issued a Warning Notice to the provider after the inspection. A Warning Notice is part of enforcement action taken by us, where serious concerns are identified. At this assessment we followed up on the previous concerns and found improvements had been made.
The providers oversight had improved, and they had supported the service robustly to help embed new systems and to strengthen record keeping. At the assessment we identified some discrepancies with version control of documents. We raised this with the provider who took immediate action to rectify.
Independent visitor reports took place routinely as another means to assessing the delivery and quality of care. They audited information and produced reports for the provider and the registered manager. This had helped to improve the overall performance of the home. Any action from audits and reports were added to the providers service improvement plan. Whilst auditing accidents, incidents and safeguarding records, extra checks were in place to review if this had been reported to the local authority, other professionals and to the CQC.
Regular reviews of records, staff meetings and feedback from professionals and young people were used by the management team to ensure the service was providing good quality safe care. Leaders shared any learning with staff members and looked at ways to improve the service.

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.
Without exception, professionals told us that the service were receptive to feedback and engaged well. Some health professionals had supported the staff with training, to enhance their knowledge, and improve outcomes for young people at the home. One healthcare professional said, “They have always engaged with appointments and supported [the young person] very well.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.
It was acknowledged that there had been opportunities for learning and growth since the last assessment in June 2023. However, the provider demonstrated they had been committed to investigating transparently, and in full, and consistently generating lessons learnt to take forward. The provider said, “We have a strong management team now and the young people and the service has grown. Documentation is there to support the service. Whether it is looking at incidents, we are always looking at lessons learned.”
There was a strong learning culture within the team. Specialist professionals from within and outside the organisation had provided extra support in some areas of learning to continually drive the skills and expertise of the staff team to the benefit of young people within the home.
The management team were open to the feedback we gave throughout the assessment and showed a willingness to continually improve the service.
The service had now strengthened the systems in place to report, investigate and learn from incidents and accidents. Investigations were undertaken following incidents and appropriate actions were taken in response. In-house clinical governance meetings took place to discuss clinical issues and agree any actions and learning.