Keychange Charity Alexander House 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 changed to good. This meant the service was now consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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.

Staff were supported by managers to deliver consistently safe care and support to people in line with the provider’s vision and values for the service. Staff told us the new managers had a clear vision for the service.

The service 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.

The service had made improvements since our last inspection. A new manager and a new deputy manager had both been appointed in 2024. The service manager has submitted an application to register with us, which we are currently assessing. This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the CQC to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

The feedback we received from people about how the new manager led the care home was positive. Comments included, “The manager is so lovely and is very good at what she does. The care home did experience a high turnover of managers in recent years, but hopefully the new one will stay the course”, “The manager is very approachable and always makes time for us, as do the rest of the staff” and “The current manager and deputy manager seem to be doing a good job of running Alex House and keeping on top of things”.

Staff were equally complimentary about the leadership approach of the new managers who they consistently described as effective and professional. One member of staff told us, “We have a good manager now who is always available and shares important information with us.” Another added, “The service is well-led by our capable manager [registered] who is fantastic. Sheis always around to talk with us.”

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

The manager encouraged an open and transparent culture where people living at the care home, their relatives, external health and social care professionals and staff were encouraged to raise concerns and without fear. The provider used a range of methods to gather people’s views about their experiences of living, visiting or working at the care home. This included regular meetings with people and satisfaction surveys. People told us they felt comfortable raising concerns with the managers and staff and felt listened to. Typical feedback included, “The staff do listen to what I have to say and respond appropriately. When I have brought up concerns the managers have always done their best to address them,” “The managers and staff are very approachable and I do feel able to talk with them about any issues I might have” and “Staff have always responded well in the past when dealing with any issues out of the ordinary we have felt the need to raise. The one concern we did raise was immediately remedied”.

The provider valued and listened to the views of staff. Staff were encouraged to contribute their ideas about what the service did well and what they could do better. One member of staff told us, “In our monthly staff meetings we are able to put across our views and opinions on improving the service, and these will act upon by the home manager.”

The service 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 were positive about the leadership approach of the managers who they said treated them fairly. Staff told us their views were respected by the managers and they felt like valued members of the team.

Managers understood the importance of having a fair and inclusive workplace for all staff to work in. Staff were provided support through relevant training to inform their knowledge and understanding of equality, inclusivity and fairness in the workplace.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment[MP1][LW2] and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The provider had established governance and monitoring systems in place however, these were not always operated effectively. This was because these systems had failed to identify and/or take appropriate action to address a number of issues we identified at our inspection including, lack of person-centred and detailed guidance for staff in relation to the safe use of ‘as required’ medicines and formal support staff should receive.

We discussed these failings with the managers at the time of our inspection. They acknowledged they needed to improve the service in these areas described above and agreed to take appropriate steps to resolve these issues. For example, the registered manager showed us an action plan they had already developed to ensure all staff received regular individual supervision meeting with their line manager and had their work performance appraised annual from now on.

This negative comment notwithstanding the provider did conduct [MP3][LW4]regularly audits to check the quality and safety of care and support people received at the care home. The outcomes of these audits were routinely used to identify performance shortfalls and make any changes as and when required to improve staffs working practices.

The managers and staff understood their responsibilities in relation to regulatory requirements around notifiable incidents. Our records indicated they continued to notify the CQC in a timely manner about any incidents and events they were legally required to. They also understood their responsibility to apply duty of candour and where appropriate apologised when things went wrong.

We saw the service's previous CQC inspection report, which was clearly displayed in the care home and was easy to access on the provider's website. The display of the ratings is a legal requirement, to inform people, those seeking information about the service and visitors of our judgments.

The service 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. The provider shared information and learning with partners and collaborated for improvement.

Managers and staff told us they worked closely with various external health and social care professionals and bodies who they regularly consulted and welcomed their views and advice. A manager said, “We work very closely with community professionals, such as the GP and community nurses, who always provide us with good advice and guideline's to help us keep residents safe.” This was confirmed by external health and social care professionals who explained they had only positive experiences of working with this provider. One told us, “They [managers sand staff] are very receptive and collaborative in caring for clients with behavioural challenges and always listen to any professional advice I give them.”

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice.

Managers recognised the importance of learning lessons and continuous improvement to ensure people living at the care home received good quality, safe care and support. The manager told us all the audits and checks the provider conducted were routinely analysed to identify performance shortfalls and learn lessons, so the service could continuously improve.