Alban House Residential 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 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 provider was in breach of the legal regulation relating to good governance.

This service scored 43 (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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The provider did not always ensure there was a shared vision and strategy, with staff knowing their role in helping to achieve these. Staff did not always demonstrate a positive, compassionate, listening culture that promoted trust and understanding between them and people using the service. Where staff had raised issues in relation to people’s experiences of support, the provider had not promptly addressed them and improved delivery.

We raised our concerns with the provider during our assessment, who agreed to address them as a matter of priority.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The management team did not always demonstrate the experience, capacity, capability and integrity to ensure the organisational vision could be delivered and people’s risks managed. They were not always alert to examples of a poor culture that may affect the quality of people’s care, as evidenced throughout our assessment of Alban House Residential Care Home.

Alban House Residential Care Home had changed ownership in October 2024. The provider’s statement of purpose was out of date and referred to the previous owner of the home. It was last reviewed in April 2024.

People did not always feel they could speak up and that their voice would be heard.

Staff had raised concerns about other staff using personal phones while providing support with meals, but this issue had not been addressed.

The provider’s whistleblowing policy and procedure was not current or in date. However, it remained relevant.

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 told us they worked well as a team. Staff were kept up to date with things affecting the overall service via team meetings and conversations on an on-going basis.

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 had failed to establish and operate effective systems and processes to assess, monitor and improve the quality and safety of the service. Risks were not being mitigated, governance systems had not identified the areas requiring improvement and when staff reported concern in relation to people’s mealtime experiences these concerns had not been promptly investigated.

Quality assurance systems and provider level auditing had failed to identify important environmental risks and risks associated with infection prevention and control. This did not evidence a proactive approach to risk management and placed people and staff at increased risk. We found not all audits had been completed monthly in line with the provider’s audit schedule.

Systems and processes failed to highlight and address improvements needed for the administration and recording of medicines and did not follow national guidelines for safe medicine practice. For example, the critical importance of administering time sensitive medicines at prescribed times, the availability of medicines trained staff at night and the lack of ‘as required’ (PRN) protocols to support safe and consistent administration.

There were not robust systems and processes to maintain accurate, complete and contemporaneous records in respect of each person living at the service. Care plans and risk assessments had not been reviewed, and information contained in these were not up to date and did not reflect people’s current physical and mental health needs. Records relating to people’s care and treatment were not always complete, up to date and information was confusing and contradictory.

Policies and procedures were not current, in date nor reviewed annually to support best practice within the service.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Staff and leaders were open and transparent. However, they had not always collaborated well with all relevant external stakeholders and agencies. For example, escalating safety concerns and the issues found during our assessment of the service.

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.

Prior to the assessment the provider had not identified all areas for learning and improvement. Whilst we did identify shortfalls during this assessment, the provider was responsive to our findings and acted urgently following feedback to begin making improvements.