Alsley Lodge

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 consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 86 (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 had introduced values-based recruitment processes, and information about the culture at the home was shared with new staff as part of their induction. Observations throughout our inspection evidenced staff had a clear understanding of the provider’s values and prioritised safe, high-quality, compassionate care.

Managers ensured the culture of the service was person-centred, empowering and inclusive; and developed through collaboration with others. A healthcare partner told us, “Staff appear to treat people with kindness, respect and compassion. Managers are equally respectful, open to feedback and demonstrate a genuine commitment to maintaining high standards of care. The overall atmosphere during visits is positive and interactions reflect a culture of respect and cooperation.”

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.

The provider ensured high-quality leadership was sustained through safe, effective and inclusive recruitment and succession planning. Managers had been recruited safely and had previous experience within the care sector. They were provided with ongoing support to undertake enhanced training and qualifications; to continuously improve their knowledge, skills and capabilities. Similar professional developmental opportunities were made available to all staff.

Staff confirmed managers led by example and modelled inclusive behaviours. A staff member said, “Managers are really approachable and always have time for you. They will work the floor and are very knowledgeable.” Throughout inspection, the deputy manager and registered manager demonstrated a good understanding of the service, it’s key issues and priorities.

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

The registered manager actively encouraged staff to raise concerns, explaining safeguarding and whistleblowing was routinely discussed in staff meetings and supervisions. Staff confirmed they felt able to speak up about concerns without fear of detriment. A staff member said, “I feel staff would be happy to speak up. In the last staff meeting, we were prompted to air our views. The registered manager wants to hear about any concerns.”

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 provider took action to prevent and address bullying and harassment. Staff had access to an employee handbook which included information around discrimination, harassment and how to complain. Several staff commented positively on their treatment from managers and colleagues. A staff member said, “Staff are very kind to me and are very friendly. There’s not been any staff that aren’t helpful, it’s a joy to come to work.”

Staff member’s rights were considered when policies were created, including consideration of the Equality Act 2010, Employment Rights Act 1996 and the Working Time Regulations 1998.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Managers had introduced and developed innovative digital systems to audit all health and safety, IPC, medicines and care interactions. Systems incorporated alerts to reduce the risk of tasks being missed in real time, and managers regularly reviewed timeliness and standards, taking prompt action to improve the safety and quality of care.

There were robust arrangements for the availability, integrity and confidentiality of data. People’s support plans and care records were thorough, and personal information was kept secure. Detailed records evidenced systems to manage recruitment, training and staff performance were effective. The registered manager explained steps taken to address staff performance. For example, extending probation periods, and offering additional guidance and support.

The provider implemented recognised standards and best practice, by ensuring policies were regularly updated, and the business continuity plan detailed their preparedness for emergencies and adverse events.

The provider clearly understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.

Managers engaged regularly with people, their relatives, healthcare partners and other services; and there was a strong focus on shared learning and supporting people to achieve better outcomes. For example, enabling relatives to volunteer at special events and taking a multi-disciplinary approach to supporting people with their mobility, diet or wellbeing.

The home was embedded within the local community and valued by others. They had strong links with the library, church, schools and services such as pop-up clothing shops, the dementia café and community farm. The monthly timetable evidenced activities and resources shared with community groups and other local care homes. These links helped people access a wider range of social opportunities, and build new relationships outside of the home; and evidenced manager’s positive approach to collaborative working.

Managers were involved with various networks; to share learning and drive improvement. They registered manager and deputy manager both attended several forums to improve their own knowledge and share good practice.

The provider had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Managers and staff had an excellent understanding of how to make improvement happen and measured the outcomes and impact of change. The registered manager spoke about investment and new initiatives to support improvement, including better analysis of incidents and accidents, introducing a second sitting at mealtimes and changes to the environment. Kitchen staff were carrying out their own research of the impact of diet on diabetes, mood and falls. The activities coordinator observed and sought feedback about what was working well for people, adjusting the monthly timetable to improve their experience.

When asked if the service actively involved staff in understanding where improvements were needed and collective problem solving, a staff member said, “We have meetings every 3 months and input new ideas. I can always knock on the manager’s door in-between meetings. I recently helped people create individual wish lists. A person wanted all their family to come for afternoon tea, so we made it happen and it was lovely.”

Simple technology was being used innovatively to improve people’s quality of life. For example, a smart speaker was used to read audiobooks to people with sight impairments, set reminders for activities and mealtimes, and play soothing music to those on end of life.

It was evident throughout inspection there was a strong emphasis on people’s quality of life and how this could be improved. A healthcare partner told us, “The home has improved. The differences made have been good ones, things seem more organised. I have no concerns about the home at all.”