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 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.

At the last assessment in September 2024, we were not assured of the providers understanding of their regulatory responsibilities. There was little evidence of management oversight in several areas to monitor the quality of service provided, record actions and identify opportunities for learning and improvement. This placed people at increased risk of harm. We found at this assessment that improvements had been made. The providers oversight had improved, and they supported the home daily to help embed new systems and to improve record keeping. A quality compliance and training manager supported the provider to improve and audit the home. They audited information and produced reports for the provider and the registered manager. This had helped to improve the overall performance of the home. Any action from audits and reports were added to the providers service improvement plan. Whilst auditing accidents, incidents and safeguarding records, extra checks were in place to review if this had been reported to the local authority, other professionals and to the CQC.

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.

At the last assessment in September 2024, we found the home lacked provider oversight and governance systems were not comprehensive. It was not checking aspects of the home where we found concerns. There was a lack of documentation in identifying areas for improvement and development. We found at this assessment; improvements had been made. Straight after the assessment in 2024, an interim manager from a consultancy service, supported the provider until the registered manager started in post. A new deputy was appointed. The provider and the managers worked together to implement changes to governance systems. They supported the staff, people and relatives through the changes, which had involved investigations and working with the local authority. Meetings were held with the staff and relatives, to keep them updated on key changes and areas which needed improvement.

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

At the last assessment in September 2024, we received mixed feedback from staff about the culture within the service. They did not always feel able to speak up and appropriate actions had not always been taken in response to incidents. We identified several incidents reported by the staff, where appropriate action had not been taken or documented to address ongoing risks to people. Staff had reported some concerns, but they had not been dealt with appropriately.

We followed up the previous concerns raised and found improvements had been made. The provider and the registered manager had worked hard to change the culture of the home and we noticed a difference in the staff morale. The staff told us they were listened to when they raised concerns and reported incidents. The registered manager and provider took action when any incidents occurred. Learning from incidents was shared with the staff through handovers and meetings. The staff were also able to see action taken from completed closed incident forms.

Staff meeting minutes recorded who had attended, what was discussed and any learning. Ongoing feedback was sought from relatives, and the registered manager told us surveys were due to be sent out again. We spoke to relatives to gain their feedback. One relative told us, “I find the managers are approachable. I feel able to point out any concerns and ask questions.”

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.

At the last assessment in September 2024, we received mixed feedback from staff with regards to equality and inclusion. Some staff raised concerns and described aspects of a closed culture. The provider’s processes used to record, learn from people’s experiences and gain feedback, had not been sufficiently adapted to the needs of people living at the home.

We found improvements had been made and the feedback from the staff was positive. The staff told us, “The management team are supportive, and nothing is too much trouble” and “I am not afraid to voice my concerns and make suggestions. Handovers and staff meetings are much better.”

The registered manager was keen to support staff in their role and had an open-door policy. The registered manager helped to adapt staff training, so that the staff understood what they needed to do. One example included the registered manager supporting a staff member during an e learning session, as the staff member needed help navigating the system.

Staff meeting minutes were shared with the staff. Newsletters had been developed for people, staff and relatives. This was to share information about the home, upcoming and past events

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.

At the last assessment in September 2024, we had serious concerns about the governance systems in place and the provider’s oversight. This included people’s care records not being up to date, to reflect their needs. No overview of people’s weights was in place, and we found some people had unexplained weight loss. We found admission assessments had not been fully completed for people, no recruitment audits were taking place, and we found incomplete recruitment processes for some staff which had not been identified or risk assessed. Audits were being undertaken but were not effective. We issued a warning notice to the provider after the assessment. A warning notice is part of enforcement action taken by us, where serious concerns are identified. We followed up the warning notice in March 2025 which included us looking at some parts of governance, where we had serious concerns. We found improvements had been made. However, we did not look at the full quality statement governance, management and sustainability.

At this assessment, we found improvements had been made. Audits at provider and service level had improved, with new audit templates developed or amended to help identify shortfalls. A robust auditing system was in place with the deputy, registered manager and provider carrying out checks of the home. Feedback from the staff had improved, regarding the leadership of the home. One staff member told us, “I can see the improvements and the changes have been positive”. Another staff member told us, “The deputy and the registered manager are keen to drive improvements, and I feel valued.”

Staff recruitment procedures were safe with a tracker in place to capture essential information, we did not identify any shortfalls. One staff member did not have two references; however, the reason was logged and this was risk assessed. The providers recruitment policy had been updated.

The provider carried out monthly and quarterly audits of the home. Monthly audits and reports were produced by the quality compliance and training manager. This included checking accident, incident and safeguarding records, to ensure sufficient action was taken. The provider was also working with a consultancy company who supported with monthly audits and mock inspections. Alongside the audits a service improvement plan was in place. In September 2024, 19 actions were logged, which had now been completed apart from 1 outstanding action.

People’s care plans continued to be reviewed by the deputy and registered manager and were checked as part of the provider’s audit. People’s care plans and risk assessments had been re written and contained information about people’s wellbeing, admission assessments and any identified risks. The provider now had an overall audit of people’s weights and were able to monitor this. This showed people had maintained their weight. Logs of bruising, infections and pressure injuries were also audited.
 

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.

At the last assessment in September 2024, health professionals told us they had faced some challenges and resistance working with the staff at Alice House. Some concerns were raised about the conduct of a staff member when visiting the home. Due to the shortfalls, we have identified regarding people’s wellbeing and weight loss, we could not be assured staff reported all concerns to the GP.

At this assessment we found that improvements had been made, with relationships improved between the staff and health professionals. The provider welcomed professionals into the home and maintained a good relationship. Some health professionals had supported the staff with training, to enhance their knowledge, no concerns or resistance were reported. The GP surgery visited weekly and the district nurse daily. One professional told us, “Things have really improved, and staff make me feel welcome. They are very good at listening; reporting concerns and recording is a great improvement.” Another professional praised the improvements made at the home and felt a difference, when visiting.

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.

At the last assessment in September 2024, staff had not received clear guidance in relation to mitigating known risks. We were not assured the provider had adequate measures to assess, monitor and mitigate the risk to people’s health, safety and welfare. The provider had failed to respond sufficiently to previous incidents of harm. Learning had not taken place to mitigate risks. At this assessment we found improvements had been made. The operations director told us they had learned from the previous failings. This included taking action in priority order, to mitigate risks and improve people’s wellbeing. Some people had moved to other homes or required funding for 1 to 1 care. Monthly audits of safeguarding, accident and incidents were taking place, with reports written and shared with the staff. Trackers were also in place, where incidents and accidents recorded the actions taken. People’s daily records were checked when accident and incidents had occurred. Where recording needed further details the management team spoke to the staff and offered them guidance and training.