Archived: Alston View Nursing and Residential 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.

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

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 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 organised regular team meetings and 1-1 meetings with staff to share the direction and strategy of the service. The service held meaningful values such as person-centred care and respect and dignity. These values were shared and adopted through induction, training, and regular updates. The senior manager aimed to lead by example and was visible in the service, and accessible to staff.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

There had been a high turnover of managers in the past 2 years and the provider recently appointed a manager to the service who did not have the right skills and knowledge to lead or deliver effective care. Action had been taken to resolve this prior to the assessment. The provider arranged for a senior manager to step in to the service to provide leadership and oversight whilst a suitable manager could be recruited.

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

There were appropriate whistleblowing and freedom to speak up policies. Staff confirmed they were confident in raising any concerns or issues and would be listened to.

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.

Appropriate policies and procedures accounted for workforce equality, diversity and inclusion. Staff said they did not have any concerns in this area.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider did not always have a good understanding of risk, and we found that risks to people’s health and wellbeing, and in the environment had not been mitigated effectively. Incidents for some people continued to occur and timely action was not taken to learn lessons and make changes to care and treatment.

The provider had not made sure there was enough levels of staffing with the right skills and abilities to meet people’s needs safely.

Although the provider understood their responsibilities regarding making statutory notifications to relevant bodies, some incidents were not reported to CQC regarding conflicts between service users which was a further missed opportunity to help identify risk and take action.

Although there was a schedule of audits, the medicines audit had not identified concerns that were noted during the assessment.

The service was without a manager who was registered with CQC, which is their legal duty to do so; however, the interim manager had begun the application process. The provider aimed to recruit a new manager with sufficient knowledge and experience to provide necessary leadership to the service and help make improvements.

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.

There were appropriate policies in place. There was good integration with external health and social care departments and information was shared effectively. Staff worked with other agencies well such as social workers, falls teams, district nurses and the local mental health teams.

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 provider did not always learn from incidents to make sure changes and improvements were made to care and treatment. We saw incidents occuring over several weeks and changes were not made, meaning some people were left at risk of harm.

The provider have assured us that significant changes have been made to their governance processes to address these issues, which we will check at the next inspection.