Allendale Residential Home Limited

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 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 75 (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 a statement of purpose which set out the values and visions of the service and was registered with the CQC to support older and younger adults and people with dementia. The home also supported people with a learning disability and those with a mental health diagnosis. The provider submitted the required documentation to add those service user bands and updated their statement of purpose. The statement of purpose included the aim to ‘maintain a relaxed friendly and welcoming atmosphere, where our service users can feel at home in a safe caring environment with the knowledge that their assessed needs will be met by our team of experienced carers with the discretion each of us would expect.’ We observed that the service worked hard to promote those values.

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.

Leaders were visible, accessible and actively involved in the day-to-day running of the service. They understood their responsibilities and communicated expectations clearly to staff.

People, their relatives, staff and professionals spoke consistently and positively about the service and its management. They described leaders as approachable, responsive and had an open-door policy.

Relatives told us, “The care home have been brilliant, and the manager has supported me as best as she can, especially as I live some distance away…The second in command (deputy manager) is exemplary and always puts residents first.” Another relative told us, “They would be hard pushed to do anything better…Anybody would be lucky to get a place living there.”

The provider had not always ensured that training and supervision for some experienced staff remained up to date. External factors had affected this. The registered manager recognised this and took action to address the shortfalls. They implemented a plan to complete all outstanding supervisions and introduced a rolling monthly programme to ensure staff training remained current.

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

The provider had a whistleblowing policy in place, which staff confirmed was accessible and understood. Staff described the process for raising concerns and demonstrated knowledge of how to escalate issues if required. They told us they felt confident that the management team would respond to and address any concerns appropriately.

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 promoted an inclusive workplace culture and treated staff fairly and equitably. The provider had policies in place to support equality and diversity, which staff understood and followed in practice.

Staff told us they felt well supported and valued by the service. They gave examples of requesting adjustments to their working patterns and confirmed the registered manager responded positively, making reasonable changes to accommodate their needs.

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

The registered manager had clear roles and responsibilities and worked closely with the provider to ensure effective oversight of the service. They used their skills, knowledge and experience to lead the service effectively and consistently. Their leadership promoted a positive culture, where staff delivered good standards of care and support in a warm, kind and friendly environment.

The provider maintained effective oversight through structured governance systems. They implemented a clear and consistent audit process. Records demonstrated audits had been completed regularly and supported effective monitoring of the service.

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 registered manager and staff worked collaboratively with a range of external partners, including health and social care professionals and private agencies to ensure people received safe and appropriate care and support.

They maintained effective communication and shared relevant information to support coordinated care delivery. We saw evidence of this in practice, including information being shared in advance of trips out to ensure people received care that met their needs on the day.

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.

The provider had systems in place to manage incidents and accidents safely and effectively. The registered manager understood their responsibilities and described how they reported incidents to relevant authorities and took action in line with organisational policies and procedures.

The provider monitored incidents and accidents and used this information to inform changes in people’s care and support where required. Staff received updates when risks changed. For example, 1 person experienced periods of distress, which could include behaviours such as aggression towards staff. Staff understood the person’s needs and were aware of known triggers and appropriate strategies to reduce distress and prevent escalation.