Albany House - Bognor Regis

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• 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 outstanding. At this assessment the rating has changed to 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.

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

This service scored 61 (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. However, they did not always understand the challenges and the needs of people and their communities.

The provider was registered as a specialist service for people with mental health needs and for people with learning disabilities and/or autism. However, the provider had not given due consideration to Right Support, Right Care, Right Culture (RS RC RC) and this meant they were not in a position to provide a specialist service to people with learning disabilities and /or autism and staff had not received all the training they needed. Following this assessment, the provider changed their statement of purpose to no longer be registered as a specialist service for people with learning disabilities and/or autism. However, there remained some people using the service who had these needs. The registered manager provided assurances following this assessment about providing additional training for staff to ensure they have a better understanding of the requirements of RS RC RC and how to meet them.

The culture of the service was positive and open. People told us they were happy living there and were consistent in their praise of the staff and leadership of the service and staff described a happy working environment.

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.

People and their relatives spoke positively about the management of the service. One person told us, “The manager is very good, and the deputy manager (Head of Care) is good, they are all good. Even the night staff.” Staff spoke positively about leadership at the service. One staff member said, “The team are brilliant and (registered manager) is a wonderful manager.” Another staff member said, “I can’t fault (registered manager) as a manager and a mentor.” A third staff member described the registered manager as compassionate and told us, “They are here a lot, they genuinely care about the people and the staff.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they felt able to raise any concerns and said their views were valued. One staff member told us there was a positive culture at the service. They said, “It’s ok to be wrong with (registered manager), she’s very diplomatic.” A staff evaluation included positive comments about staff support, including how the registered manager was always available for staff and was ready to listen and help.

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 described the service as being fair and equitable. One staff member explained how they worked at night but continued to feel included and part of the team. They told us, “I get to see (registered manager) in the mornings and in the evenings when I come on duty, and at team meetings. I don’t feel detached at all.” Another staff member explained how they were encouraged to share their experience from working in other services. They said, “The staff are all willing to listen and to share what they have learned.” One staff member said they had received support from all their colleagues saying, “It’s like a small family and we all help each other out, I’ve had so much support.”

The provider did not have clear responsibilities, roles, systems of accountability or good governance.

Systems for governance and management oversight were not robust. Shortfalls in the assessment, monitoring and management of risks had not been identified and addressed through the provider’s auditing systems. For example, audits and reviews of care records had failed to identify omissions in risk assessments and care plans including for people’s mental health and physical health needs. Audits of medicine administration had not identified the lack of PRN protocols, this was not in line with the provider’s medicine policy or good practice.

Some information within care records was inconsistent, for example a medicine care plan referred to use of a traffic light system, but staff told us this was no longer in use. Records relating to people’s mental capacity were not always accurate.

The provider had failed to ensure staff had a clear understanding of their roles and responsibilities with regard to Right Support, Right Care, Right Culture and this meant care was not always assessed, planned and arranged in line with current best practice.

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.

Staff described positive working relationships with health and social care partners. One staff member told us, “We work closely with the mental health team, Community Psychiatric Nurse and the GP. They all give us good advice and positive feedback.” We received positive feedback from a health care professional, they told us, “The staff will contact the professionals involved with the resident’s care and involve them in a meeting with the resident to come to a good agreement of ways to move forward.” Another health care professional told us, “I have always had my concerns regarding residents mental health taken seriously and have been able to work collaboratively with the care team.”

Care records we sampled included advice received from health and social care professionals. One example included working with the health care professionals to provide end of life care to a person who wished to remain at the service.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

Systems to identify learning and make improvements were not always effective. The provider had not identified shortfalls in the skills and knowledge of staff for example, in relation to supporting people with a learning disability or in people’s individual mental health needs. One staff member told us, “We could do with more training, for example how to identify triggers for people, and what to do.”

The provider had a service improvement plan in place to drive improvements they had identified, this included environmental improvements and shortfalls identified through audits. Following this assessment the provider submitted evidence of planned training in relation to supporting people with learning disabilities.