Althorpe Residential 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.The service was in breach of legal regulation in relation to premises and equipment, and governance at the service.

This service scored 54 (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. Management engaged with people and staff and had an open-door policy. Staff told us they were treated fairly and with respect. They spoke positively about how they worked as a team and felt supported.  One staff member told us "I like the hours I do and the people that I work with."

Managers and staff did not share an understanding of the risks and issues facing the service. Legal requirements were not always understood or met. Managers were not always clear about their responsibilities. However, theregistered manager was passionate about the service and wanted to ensure that it was welcoming and supportive. Our assessment identified multiple missed opportunities for the management team to ensure that the service was safe and effective. The provider and registered manager were responsive, open, and honest throughout the assessment and recognised that considerable improvements were needed and responded positively to feedback given.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There was regular informal engagement with people and those close to them. Relatives described good communication with the service, which enabled them to express any concerns, which the managers listened and responded to. However, there was limited evidence of actions taken to act on and manage these. There were policies in place on safeguarding and whistleblowing and staff were aware of how to whistle blow should the need arise.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who workedfor them. A staff member told us “I am treated fairly well, I think, and feel that I am a valued team member”. The management team were flexible and adjusted their role or working hours if needed in response to an illness or staff shortages.

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’s quality assurance systems did not identify the concerns we identifiedat this assessment. and were not used to drive improvement. For example, high risk items identified in assessments carried out by external professionals which could impact on people’s safety and wellbeing were not completed. For example, Fire, Health and Safety and Infection Control.The provider did not always ensure the management of medicine and associated records was safe and in line with guidance.The provider could not demonstrate that all staff had completed sufficient training to equip them to deliver safe and effective care. The provider had not fulfilled their regulatory requirements to inform CQC of notifiable events. These were submitted after our assessment.

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.The registered manager was aware that improvements were needed to strengthen partnership working and support improvements at the service. Recent advice from health professionals had been sought. However, timely action had not always been taken to ensure people’s records were reflective of the advice given to enable staff to improve practice. Staff encouraged people to remain part of the community by arranging various outings and visits within the local area.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome, and quality of life for people. They did not actively contribute to safe, effective practice and research.The provider and registered manager did not understand the principles of good quality assurance systems. They were not always able to identify areas for improvement. This meant there were missed opportunities to address shortfalls in the safety of the service. There was little evidence of learning, reflective practice, and service improvement. Information to support performance monitoring and making decisions was unreliable or not gathered. For example, the provider did not always ensure incidents and accidents were thoroughly reviewed to help identify themes, triggers or trends that would require further action to be taken. We saw no evidence of learning from incidents in staff meetings or supervisions.