Albert House Nursing 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 good. 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 good governance.

This service scored 62 (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 recognised the importance of maintaining a positive culture where everyone is included in decision making processes. At the time of the assessment, the provider told us they were reviewing company values to strengthen a shared vision for the service. Recent away days had been held to review communication styles within the management team. Staff and leaders reported feeling supported, demonstrated a positive approach to the service, and respected the human rights and diverse needs of both people and staff. One staff member said, “I think this is a good organisation. They care.”

The provider had inclusive leaders 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. During the site visits, leaders were visible, engaged, and actively supported the assessment process. The service had an established registered manager in post, and staff spoke positively of the support they received from management team. People and their relatives said they felt comfortable raising any concerns; however, most reported they were not familiar with the individual members of the management team. Although governance systems were not always effective, the management team was open, honest, and responsive to feedback, taking prompt action to address the shortfalls identified during the assessment. The nominated individual told us they initially chose not to implement significant changes when they began working with the service to maintain continuity. However, they had since started developing plans for improvement, including new governance and IT systems. Health professionals we contacted shared positive feedback about the leadership team. One health professional commented, “The management is competent and approachable.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt supported, and managers were approachable and available to provide support where needed. Staff felt confident any concerns would be addressed. One staff member said, “Yes, always they are on the floor.” Another staff member said, “Yes I can approach any of them including [provider].” There were several ways for staff to speak up, such as team meetings, supervision, staff surveys and a suggestion box. Although feedback was positive, we noted only a small proportion of staff responded to surveys. The provider had procedures in place to support staff in raising any concerns and contacting outside agencies as needed.

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. During the assessment, the provider told us they were working with people who use the service, their relatives, and staff to review and update the company’s values. The values being developed focused on creating an inclusive and positive culture where everyone is treated as an individual. The management team explained how they supported the diverse needs of staff, including those with protected characteristics, for example, by respecting and supporting people’s religious beliefs. Staff received training in equality and diversity and spoke positively about their experiences working at the service. One staff member said, “I am happy here; I feel valued as a member of staff.”

The service did not always have clear and effective governance, management and accountability systems. They did not always act on the best information about risk or share this securely with others when appropriate. Audits completed at service level did not identify or address shortfalls found during this assessment. For example, audits of care plans were not effective in identifying and addressing the shortfalls we found with people’s risk assessments. Audits did not address shortfalls related to the emergency grab bag, medicines competencies, and environmental risks. Management oversight did not always ensure all appropriate actions were taken in response to incidents, including notifying the CQC. We found processes in place to audit risk assessments and staff supervision required further development to ensure they were sufficiently robust. While the provider was present and responsive during the assessment, we found provider oversight was insufficient to effectively check and monitor areas where issues had been identified. Governance processes had led to some improvements in addressing individual risks since the previous assessment. The management team responded positively and promptly during the assessment, providing evidence of actions taken to address shortfalls. The provider told us they had identified governance as an area for improvement and had plans to implement a new system of audits and checks.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The management team told us how they worked in partnership with professionals such as the GP, local authority, and community mental health team to meet the full range of people’s individual needs. Following the last assessment, the service had worked with the speech and language therapy team to improve risk management for people with swallowing difficulties who required a texture modified diet. People and their relatives confirmed the GP carried out regular visits to the service and people had access to health appointments when needed. Health professionals who worked with the service told us there was good communication between the management team and external agencies.

The service had not always focused on continuous learning, innovation and improvement in the service. At the last assessment, some risks were not adequately documented in care records which meant there was a lack of clear guidance for staff to follow to manage risks. At this assessment, whilst some improvements had been made, we found examples where some individual and environmental risks had not been sufficiently assessed and mitigated, learning was not always well documented. The management team told us they were working around some limitations in their electronic care planning system; we noted this issue had been raised by staff at the last assessment but had not yet been fully addressed. There were processes in place to involve and gather feedback from people, their relatives and staff. These included meetings, surveys and a suggestion box. Whilst relatives told us they felt able to approach staff as needed, the majority told us they had not been asked for formal feedback. Whilst feedback was positive, analysis of surveys completed for relatives and staff showed a low response rate. In response, the provider told us they had established several ways to encourage relatives to share their views. The management team was committed to providing a good service and responded promptly to shortfalls identified during the assessment. The provider was keen to promote ongoing service development and improvement and shared their plans to improve the consistency and quality of care records, governance and IT systems.