Alpine House

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 not always consistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance at the service.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Improvements were needed to the systems in place for the oversight of the management of risk. The provider and registered manager were very proud of their service. When discussions took place regarding some gaps in their systems, the registered manager was not always receptive to this feedback and able to respond in a proactive way. In addition, when we requested clarification and further information around issues we had identified, assurance was not always offered at the time but was provided in emails several days later.

Staff meetings minutes indicated low attendance at these meetings. Following discussion with the registered manager and provider, they told us online meetings would be arranged which would enable more staff to attend the meetings. Staff told us concerns would be acted on by management. People and relatives told us staff were kind and compassionate. Staff and management fed back passionately about the care being delivered to people.

The provider and registered manager were keen to share with us examples of where they had gone above and beyond their role to do things for people. They shared with us the following examples: staff styled a person’s hair before a family wedding, staff sat with a person on palliative care outside of their allocated care hours, staff took a person for an outdoor walk, and staff played piano for a person who loved music who could no longer play.

The service had leaders who understood the context in which they delivered care, treatment and support. Leaders were visible within the service. There was a stable management and staff team. People, their families and staff knew who the management team were, and how to contact them. People and relatives told us the management team was caring and approachable. Staff knew their roles; they told us they felt supported and valued by the management team. A staff member told us, “I really enjoy my job, and the manager is very supportive.”

The provider told us they promoted a culture where people felt they could speak up and their voice would be heard. Staff felt confident to raise concerns if needed. Staff were positive about the management team. A staff member told us their training included safeguarding and how to keep people and themselves safe. Another staff member told us, “If there are any problems, we just go the manager, and they sort things out.”

The provider had processes to inform staff how to whistle blow. Staff had their practice observed to ensure any training and learning was applied.

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. There were systems in place for matching staff to people, for example, if a person wanted a male or female member of care staff. There were processes for staff recruitment and induction. Staff received training relevant to their roles.

The provider told us about the number of ways they supported their staff team. This included flexible working during religious festivals and to support staff with childcare commitments. They also offered support and advice to staff members during difficult times so they could remain working for the provider.

The provider’s governance systems were not always effective. These systems had not enabled the provider to address the shortfalls in quality and risk we identified during our inspection.

The arrangements for data and records were not robust. Following our site visit and review of records we held a feedback meeting with the registered manager and provider. We highlighted a number of care records and risk assessments lacked detail and guidance for staff to follow. Several days after the feedback session the registered manager sent us additional records that contained information regarding some of the concerns we had highlighted. The provider and registered manager did not refer to these additional records during the inspection process. The registered manager told us they had implemented a new record system in January 2025 and were still adapting to the system, and some records were held under separate electronic folders. The registered manager told us they had shared ‘core care plans’ with us and in addition to these, there were some specialist sections and risk assessment addenda. The provider failed to refer to these at any time during the inspection process or feedback session and their own review of their ‘core care records’ and risk assessments failed to make any reference to the additional records. There was a risk that information could be missed.

We made 5 separate requests for data in relation to care call monitoring from 14 May to 03 June 2025, so we could complete some analysis to see if people were getting their calls on time and for the right duration. The information we received was incomplete, and we had to continually repeat the request. The shortfalls we identified related to calls unscheduled, late calls, missed calls and only one staff member showing for part of a call where 2 staff were needed. We asked for reassurance because the provider’s own audits of care calls did not identify any of these concerns. When we shared our concerns about the monitoring of calls with the provider, they provided different explanations for the shortfalls we identified which they said were to do with problems relating to the call monitoring system. However, this was not made clear in any audits of care calls they had completed. The provider told us there was shortfalls with the system and they were in the process of exploring an alternative call monitoring system.

The records in relation to staff recruitment were difficult to access. To review a staff member’s recruitment records we had to access multiple separate folders to glean the information needed.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

Staff told us they could make referrals to health and social care professionals via the management team. They told us how they had recently liaised with a district nurse to get pressure-relieving mattress urgently and also worked with healthcare specialist teams.

We received only the contact details for a limited number of health and social care professionals from the provider. One healthcare professional told us they worked well with the provider and had no concerns. They told us, “We find that Alpine House send copies of care records when requested and respond quickly to queries. They are always happy to support and take additional training when offered.” Another health care professional told us it took several attempts for them to get the information they needed from the provider.

There was some evidence of learning and improvement across the organisation. There was positive feedback from people, relatives and staff and this had been captured by the registered manager and included information about when they felt they had gone above and beyond in providing a service to people. However, it was not always clear how the registered manager and provider had used reflection and collective problem solving to continuously improve the service. The provider’s systems and processes for assessing and monitoring the safety and quality of people’s care were not always robust or effective. Our inspection identified a breach relating to good governance.

The service supported a small number of people with a learning disability and autism. The provider was aware of specific guidance including Right support, right care, right culture and staff had received specific training so they could support people.