Alma Lodge Care 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 Requires Improvement. At this assessment the rating has remained Requires Improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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.

The provider told us of their shared vision and culture, but improvement was required to ensure it was embedded throughout the service. The provider was committed about ensuring that people received support based on equality and human rights, and diversity and inclusion. However, the lack of ancillary staff to support the running of the home impacted on care staff being able to perform their role in promoting person centred care and meeting people’s health and social needs consistently. We were told that having to cook, clean and do laundry took them away from people and that sometimes care and support was then rushed.

The registered manager and staff understood and supported people’s cultural and spiritual needs. People were treated equally, and their individual needs were met in line with their preferences.

Not all leaders showed they always understood the context, displayed the skills, and credibility to lead effectively. Some people told us concerns were not always addressed quickly by the management team. These involved waiting for assistance in the morning and not enough staff in the evening and the lift not functioning since September 2025, which had impacted on peoples’ appointments and ability to go out as they wished.
We were not assured that suitable systems were in place to ensure all incidents, hospital admissions and events that stopped the running of the home were notified to CQC, as we found some which should have been notified and were not. We discussed this with the management team and clarified that not all incidents and hospital admissions needed to be reported to CQC, however, their response did not assure us there was a clear understanding around regulatory responsibilities in relation to notifications that should be submitted to CQC or external organisations as required in a timely manner.
Not all accidents and incidents and lessons learned were documented. This put people at the avoidable risk of repeated accidents and incidents within the service.
Audits and reviews of care plans were in place. However, these had not picked up on some of the concerns we found in relation to some care plans not in place, not being person centred, and some risk assessments not having enough information on how to manage individuals care needs.

The provider told us they fostered a culture where staff could speak up, and their voice would be heard. We requested evidence of staff meetings but have not yet received them. The management team had an open-door policy, which enabled staff to approach with views or concerns if they wished to do so. Staff told us they had opportunity to speak with the registered manager when they were at work. They told us that some improvements were happening in respect of the environment, but there were still environmental challenges occurring, such as the lift still not functioning fully and they had to changes fuses. The lack of formal staff meetings meant that actions discussed could not be followed up to reassure staff they were listened to.
The service had a whistleblowing policy in place to support staff with speaking up. Contact information for the complaints, and local authority safeguarding team was displayed in a public location in the service so staff would be able to make contact without the knowledge of their managers if they felt the need to do so.

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.

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. Several members of staff had worked at the service for over ten years.Different culturesand religions were represented within the workforce and staff told us that any requests for changes in shift or days off due to wanting to celebrate feast days had been supported by managers. Equal opportunities and equality and diversity policies were in place and although not reviewed recently, remained fit for purpose.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.
Whilst there were audits and systems in place to govern the oversight of the service, these had not identified and/or addressed many of the issues we found on inspection. For example, the poor general cleanliness of the service, had been noted but not acted on, the audit for care plans had not picked up that there were missing care plans, the diabetic audit stated that there were diabetic care plans in place, but no care plans had been completed. We also found that people had not been weighed since August 2025.
Not all accidents and incidents and lessons learned were documented. This put people at the avoidable risk of repeated accidents and incidents within the service.

Staff received supervision and spot check sessions which included checking their knowledge in areas of care and support they delivered. However, when we spoke to staff at the inspection, they were unable to give a brief explanation of best interest decisions and the Mental Capacity Act 2005 and the impact this would have on people. This left people at risk of being supported by staff who did not fully understand how to support them with their independence, choice and control. The registered manager was in contact with the local authority regarding this and would receive support and training.

.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.
People were consistently supported across a range of different services and agencies. There were established systems in place to liaise with other professionals. These were opportunities to share knowledge and learning and consider future developments.
The provider and registered manager worked cooperatively with partners and commissioners. However, this needed to be reflected into the care documentation, so all staff were fully aware and kept up to date with any changes and to support people safely.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.
They did not always actively contribute to safe, effective practice and research. Because of the recent lack of robust auditing and quality monitoring there was no record of learning lessons from when things went wrong. Accidents and incidents were not all recorded and whilst discussed at handover or daily meetings’ there was no written record of these conversations.
The current care plan system was not embedded into everyday use at this time. The registered manager was planning to request support with the system to ensure it was functioning properly. The absence of recorded staff meetings meant that staff did not routinely have the opportunity to raise concerns or best practice with managers and receive action points to take forward.