Albemarle Hall 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.

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 statement of purpose contained the values of the home and staff acted in line with these.

Staff members were able to demonstrate that they reflected the homes values by displaying kindness, empathy, engagement and respect.

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.

Staff had regular supervisions and appraisals. Staff felt able to approach management and make suggestions. People’s relatives told us communication with the staff was good and they could always get through when they rung the home. People also spoke about different forms of communication between the home and relatives. People and relatives knew who the management team were and felt they were approachable. One relative stated that although she did not always agree with the registered manager’s ideas, that overall she did have complete trust in the home. A staff member told us they are able to suggest changes and talk to the registered manager about any improvements.

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

Staff told us they felt that they were able to speak up and share concerns. They said they felt comfortable approaching the management team with any concerns and were confident action would be taken. The whistleblowing policy was available in the entrance of the home.

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.
Staff received regular supervisions. Staff were treated fairly and were given equal opportunities. A staff member told us they saw management in the home regularly and they felt supported. The staff member also stated the registered manager is receptive to suggestions and will listen and make changes.

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.

We identified that the provider had failed to submit statutory notifications for allegations of abuse and a police incident to the Care Quality Commission. These notifications are a legal requirement and must be submitted promptly to ensure regulatory oversight and safeguard people using the service.

There were governance and management systems in place however, these were not always effective. There were many audits completed however, these did not always provide effective oversight or identify areas requiring improvement. For example, we observed an individual’s medical file stored outside their bedroom on 2 consecutive days, not in line with best practice and potentially breaching that person’s confidentiality. We also found oversight did not pick up environmental concerns such as the hot water temperatures being a scalding risk to people and the keys to the medicines cupboard and medicines fridge left in the locks. A business continuity plan was in place demonstrating preparedness for service disruption.

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 service worked closely with the GP and had a frailty nurse regularly onsite. The home worked well with a local dentist and optician, enabling people access to these on a regular basis as well as when required. The service worked in partnership with others for people’s benefit.

The provider focused on continuous learning and improvement across the organisation.

There was evidence of learning to drive improvement. For example, management had identified staff were using vague language in care records. This had been discussed at a subsequent staff meeting with action to improve practice. The service completed a range of audits. The home had a development plan in place with actions both completed and ongoing. The service had sought additional hydration training for some staff members. People have been supported to use technology to see relatives when an onsite visit has not been possible.