Aldringham Court

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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last inspection this key question was rated good. At this assessment it has remained good. This meant the service was 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 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.

There were a range of meetings for staff, including clinical and nurse meetings, health and safety meetings, nutritional meetings and whole staff meetings. The minutes to meetings demonstrated any changes in people’s wellbeing, lessons learned and updates on the requirements of their role were discussed. The registered manager told us, “A daily catch up meeting is held with the head of departments, brief but meaningful and helpful for each department on what to expect on the day.”

A staff member said, “The management team provides clear guidance, supports staff with training and supervision, and ensures policies and procedures are followed. This creates a positive culture where staff feel supported, and people using the service receive safe, high-quality care."

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.

Since our last inspection, there had been a change in the management of the service. The registered manager told us they had been working in the service since August 2023. The registered manager told us about the improvements put in place since they started working at the service. There was a service improvement plan in place to monitor ongoing improvement.

The registered manager was supported by a clinical lead staff member, as well as organisational leaders who also monitored the service delivery.

Staff told us they felt the service was well led and the registered manager, and management team valued their views and addressed any concerns they had.

People and relatives told us they knew who the manager was, and that they were approachable and listened and acted on concerns. A relative said, “The manager’s door is always open to residents’ family and is very approachable and leads [their] team and home very well."

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

Staff were empowered to share their views of the service in both team and 1 to 1 supervision meetings. The registered manager told us they operated an open door system and staff, people using the service and relatives could approach them at any time.

There was a whistleblowing policy in place, which was understood by staff. A staff member said, “I feel confident that if I had any concerns, I would report them promptly to keep people safe.”

People and relatives told us they felt their feedback about the service was valued. Regular resident meetings and relatives’ meetings were held and information was posted on what actions had been taken as a result of comments received on a ‘you said, we did’ board. Annual surveys were undertaken, the management team told us the surveys for this year were planned.

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.

The registered manager told us how the staff team were diverse and they worked together as a team and were respectful of each other. This was confirmed by staff who felt they worked in an inclusive culture, where their diversity was respected. The registered manager said, “Our staff are trained to recognise equality, diversity and human right issues and how they are to put these into practice in the course of their workday."

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

There were systems in place to monitor the services provided, this included a range of audits to support the management team to identify and address any shortfalls in care quickly. However, we had identified care plans were not always being fully updated when people’s needs changed and to reflect guidance from health professionals, and some shortfalls in the management of medicines, repositioning records and daily notes. Although actions were taken or planned to be taken, they had not all been independently identified and addressed prior to our assessment. changes in people’s needs. Lessons were learned from incidents, accidents, complaints and safeguarding to reduce future risks.

A service improvement plan was in place which ongoing improvement.

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.

The manager told us they had good relationships with other professionals involved in people’s care. This included commissioners, and the GP service, who undertook weekly visits to the service, and further visits, as required.

People were supported to access the community, where able, including outings to local points of interest. The registered manager told us how the service was supported by community groups, such as representatives from local places of worship, who visits the home.

The provider 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 and research.

There was a programme of training provided to staff, and they were reminded when this needed updating. Actions were taken by staff to ensure their training was current.

The provider’s service improvement plan evidenced the provider and the management team were committed to ongoing improvement.

The provider ensured lessons were learned across the organisation, this was supported by registered manager meetings, and monitoring of the service by the provider’s leadership team. The electronic auditing system allowed the provider’s leaders to remotely monitor ongoing improvement and any areas of concern, which would be followed up by the team.