Alexandra 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 Inadequate. 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 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 visions and values in place which centred around safety, responsibility, care, bravery and individuality.We found staff and the management team displayed these values to ensure people received safe and effective care aligned to their needs. The registered manager told us of all the changes they had made since our last assessment including further training and supervisions to improve the culture of the service. We found staff now carried out their roles in line with the providers 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. There were now clear systems for escalating concerns. When issues arose, staff and the management team knew exactly who to contact to get issues resolved quickly. The providers senior leadership team were now also more involved which ensured the significant improvements required had been made. The management team knew their roles well and identified areas for improvement to keep people safe from harm. We found audits had been completed and findings shared with staff. Staff respected the management team and told us,“The managers are great here, they’re really approachable and always act on things.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff said the management team and provider listened to them when they reported concerns about the service. Staff meetings were held following our last assessment to ensure all staff felt empowered to raise concerns should they need to. Staff told us, they would not hesitate to raise concerns if needed and knew who to escalate concerns to outside of the home management team. We found staff were supported in supervisions and meetings to share concerns in their preferred environment. There was a whistleblowing policy available to staff.

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 explained following our last assessment expectations and culture were discussed at meetings and supervisions to ensure all staff felt they were treated fairly. Staff completed equality, diversity, and inclusion training. Staff had access to the services policies and systems.

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. Governance systems had improved significantly since our last assessment. The registered manager now ensured a monthly report was sent to the providers leadership team, to show what they had found during management checks. This ensured any actions needed following audits were completed. All the issues we found at our last assessment had now been addressed. This meant the provider now acted on known concerns to drive service improvement.

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. People told us they were fully involved in planning their care. People said, staff asked their opinions and implemented any changes required. People were supported to integrate with the local community to improve their experience. Staff told us they shared a minibus with other services and could access community events if people wished. Feedback we reviewed demonstrated the service had worked effectively with external partners such as the local authority to improve the quality and safety of care.

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. We found there was now an effective system in place to drive service improvement. Audits in place now identified issues and significant improvements had been made. The provider accepted and acted upon all our findings following the last assessment and used it as a learning opportunity to improve the service. Improvements to care plans, the environment, monitoring of people’s health needs had all taken place and new processes embedded to ensure the safety and quality of care improved.