Alice 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 the assessment in September 2024, we rated this key question inadequate. At this assessment, the rating remains inadequate. This meant some systems in place for governance and management were not always effective.

This assessment has shown the provider has addressed the concerns outlined in the previously issued warning notice relating to good governance. Although sufficient progress has been made, further improvements are needed to strengthen management oversight in some areas and fully embed the changes introduced. Not all outstanding breaches of regulation were reviewed during this assessment; therefore, the provider remains in breach of the legal requirement relating to good governance. These outstanding breaches will be reviewed at our next assessment.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At the last assessment, service level and provider oversight was found to be insufficient. A number of significant shortfalls were identified, including incidents not being reported to the local authority safeguarding team and the CQC as required. At this assessment improvements had been made against shortfalls detailed in the warning notice relating to good governance. A new manager had been appointed since the last assessment who was in the process of registering with CQC. A newly appointed nominated individual was also in post. The provider was working with a consultancy, who were supporting the service to improve their governance systems.

We found governance had improved, with new audits and processes implemented, along with an overall service improvement plan. This included the oversight of medicines, infection and prevention control, care plans and risk assessments. Although improvements had been made, further work was needed to embed changes and further develop governance processes relating to staffing, recruitment and safeguarding.

For example, the manager and provider were carrying out regular audits of incidents and safeguarding concerns, with new audits introduced. Records showed timely action had been taken when safeguarding concerns had been identified. Incident records were audited to identify trends, patterns and actions. However, safeguarding audits completed lacked the same level of detail and analysis. The provider told us they would review these audits and make further improvements.

There had been no new admissions to the service since the last assessment. The manager explained steps had been taken following the previous assessment to address the lack of admissions assessments. This included working with health professionals and relatives to develop people’s care plans. The manager told us how people’s needs would be thoroughly assessed prior to any future admissions to the service.

At our last assessment, although people’s care records were reviewed by the registered manager, the system in place did not identify and address the issues we found with care plans and risk assessments. There was a lack of information recorded about people’s needs and how risks were to be managed. During this assessment, we found care plans and risk assessments were being regularly reviewed at both the service and provider level. Improvements had been made or were planned to enhance oversight of risks related to weight loss and people’s distressed behaviours. The management team told us work to improve the quality of people’s care records were ongoing. For example, the electronic care planning system had recently been upgraded to better support the recording and analysis of people’s behaviours.

At the last assessment, no audits were undertaken of recruitment procedures. We found incomplete recruitment processes for some staff which had not been identified or risk assessed. At this assessment we found a recruitment tracker had been introduced. However, further improvements were needed, to ensure it was consistently updated and actions were clearly documented.

The oversight of staffing levels had improved, supported by the recent introduction of a new dependency tool which supports the provider in assessing safe staffing levels. Further improvements were needed to the dependency tool to ensure the layout of the environment was considered. Following the assessment, the provider submitted an updated dependency tool, which considered the environment. This will require time to be embedded. We will follow this up at our next assessment.

Oversight of medicines had improved at service and provider level. Audits were being undertaken of medicines including controlled drugs. Discontinued medicines were appropriately logged and returned to the pharmacy, with a clear audit trail in place.

We spent time talking to the staff about what changes had been made since the last assessment. One staff member told us, “I feel much more supported, the manager is approachable and nice. I enjoy coming to work. Another staff member told us, “I have seen lots of changes, some residents have been moved, it used to be really challenging. Things are more manageable. The manager’s door is open, and she cares about us and the residents.”