Adalena 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 andgovernance 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 haschanged to Requires Improvement. This meant the management and leadership wasinconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance and oversight at the service.

This service scored 57 (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 culture based on transparency, equity, equality and human rights, inclusionand engagement. They had a culture based on these, and understood the challenges and theneeds of people and their communities.

Staff we spoke with said they felt there was a culture of collaboration at the home with care staffand the registered manager working closely together and they felt valued and listened to. Staffalso told us how they upheld people’s human rights, considered their protected characteristicsand were able to explain the diverse challenges that people with learning disabilities mayencounter.

Leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills and knowledge to lead effectively.

We could not be assured that the registered manager had enough time or support to undertake their managerial duties effectively. Audits in relation to infection prevention control, health, medications or quality of care or culture had not always been completed. Care documentation sometimes lacked accurate, robust and detailed information on people’s needs. However, the registered manager was visible, present and open to our suggestions for improvement. Staff told us that the registered manager was knowledgeable, supportive and inclusive and that their ideas were valued.

The provider fostered a positive culture where people felt they could speak up and their voicewould be heard. They did not always have procedures in place to capture people’s feedback.

The provider did not hold any documented meetings between staff and management to capturethe thoughts and views of staff. Policies were in place to support whistleblowing; however, wecould not be assured that these were up to date or reflective of current best practice.

However, the registered manager told us that they felt comfortable to speak up and raise anyconcerns with the nominated individual. Care staff told us that they felt comfortable to speak upand share concerns and feedback with the registered manager. Care staff told us thatcomprehensive verbal handovers took place, and that they used these opportunities to raise anyconcerns or feedback they may have with the registered manager.

The provider did not have systems in place to monitor diversity in their workforce. They did work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The workforce of the service consisted solely of female staff; this was not reflective of the people who live at the service. We did not see any evidence that the provider sought or monitored its workforce for protected characteristics. However, staff we spoke with were able to tell us about protected characteristics and displayed an understanding of equality and diversity. Staff told us what discrimination, bullying and harassment might look like for them. Staff told us they would feel confident to report any concerns without fear of reprimand.

The provider did not have clear systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes. They did store information securely.

The registered manager was not clear on their regulatory responsibility around submitting notifications and safeguarding concerns to us. There was a lack of audits around health, medications and care quality. We were told that supervisions and appraisals took place with staff, but these were not documented. The registered manager told us that these things all took place dynamically, as they felt that the service was small enough to monitor these issues without requiring documentation. This is not in line with best practice. We did not see any evidence the provider had an appropriate data security toolkit in place to demonstrate they practiced good data security. However, we did see that personal information and data was stored securely.

Staff we spoke with told us they felt the service was well organised and managed, and we observed that people’s care documentation was stored securely. The provider had a business continuity plan in place. This is a documented framework of procedures and instructions that enables providers to continue operating during and after unexpected disruptions, such as loss of electricity, floods or fires

The areas of concern we identified on inspection could reasonably have been expected to have been identified by effective governance systems.

The provider understood their duty to collaborate and work in partnership, so services workedseamlessly for people. They shared information and learning with partners and collaborated forimprovement.

The registered manager told us about their experiences of working alongside other partnerswhen seeking help for people. They understood their duty to collaborate and work in partnershipto ensure positive outcomes for people. They shared information and learning with partners andcollaborated for improvement.

Management and staff worked with health and social care partners, and the local authorities todrive improvement and meet people’s needs. Care records that we viewed recorded people’sappointments and learning disability reviews.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The registered manager did not not attend or take part on any care related forums, meetings or peer groups to actively develop their knowledge and keep up to date with current best practice. We were told that they did not have the time to attend these meetings. Although we were told of plans to re-design some aspects of the home in order to better suit the needs of the people who live there, we did not see any evidence of quality assurance systems to monitor and continually improve the service.