Alt Park 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 requires improvement. At this assessment the rating has changed to inadequate.This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

At the last assessment, the provider was in breach of legal regulations in relation to good governance. At this assessment, not enough improvement had been made,and the service remained in breach of the legal regulations in relation to good governance.

This service scored 36 (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 failed to establish and embed a shared direction and effective culture. The culture within the staff team did not promote the recognition or escalation of concerns. For example, concerns in relation to the standard of people’s personal appearance and the maintenance and cleanliness of the care environment. This increased the risks to people’s safety and did not promote a culture that supported sustained improvement to the quality and safety of the service.

The provider did not have leaders at all levels who fully understood the context in which they delivered care, treatment and support. The registered manager did not always recognise and address poor practice with staff including safety concerns and a lack of respect and dignity for people based on our observations.

While we had confidence in the registered managers ability to reduce risk following our feedback, significant improvements were needed to ensure they retained overall oversight of all aspects of care provision and developed a more effective monitoring system that was proactive in identifying and reducing risk in a timely manner.

The registered manager mostly fostered a positive culture where people felt they could speak up however, further improvement was needed to ensure leaders encouraged staff to speak up about concerns that impacted the safety and dignity of people. For example, we found no evidence staff had spoken up about the issues we found during the assessment.

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. Different cultures, faiths and backgrounds were represented within the staffing team. Staff told us they felt supported in their roles and diversity was promoted. Comments included, “I’m from another country, [registered manager] is doing a really good job trying to make everyone feel comfortable."

The provider did not implement effective governance systems. They did not act on the best information about risk, performance and outcomes. Overall, there was a lack of oversight and scrutiny of the service by the provider and the registered manager to ensure risks were identified and mitigated. Audits and checks were completed; however, they were not effective at identifying all concerns and improving the quality and safety of the service. For example, daily walkaround checks to assess the safety of the environment, medication management audits and infection prevention and control audits did not identify the extent of the concerns we found. The absence of effective audits increased the risk to people as opportunities to identify concerns were missed and risk was allowed to continue unchecked, as evidenced by our findings.

The provider did not fully understand their duty to collaborate and work in partnership, so services work seamlessly for people. People and their relatives were not fully involved as partners in their care as records did not evidence care planning was carried out collaboratively.We also found health professionals were not always informed when people’s health conditions changed, resulting in delays to them obtaining treatment.

There was a lack of partnership working with CQC. Despite previously being informed where improvements were required, we found the provider failed to effectively drive these improvements. For example, in a previous action plan the provider told us the action they would take to strengthen accident and incident monitoring processes. At this assessment, we have continued to see shortfalls in the analysis of accidents and incidents.

The provider did not effectively focus on continuous learning, innovation and improvement across the organisation. While there was some evidence the registered manager was taking steps to develop the learning culture at the home, we noted that similar concerns had been identified at this assessment that were identified at the previous two assessments, specifically in relation to medicines management, accident and incidents analysis, ensuring care plans were up to date and governance arrangements. At provider level, we were not assured effective learning had taken place from feedback at previous assessments to drive the necessary improvements to the quality and safety of the service.