Albany Lodge

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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation and promoted an open, fair culture.

This is the first assessment for this service under a new provider. This key question has been rated requires improvement. This meant people’s needs were not always met.

We found concerns with the effectiveness of how the service operated their governance systems and responded to issues found. This is a breach of Regulations, Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Systems to monitor the quality of the service were ineffective. Audits were not being completed which would provide information for the registered manager to identify the issues found during our site visit. There were concerns with training and supervision records, risk assessments and care plans for those with high dependency needs.

The registered manager told us there were new IT systems in place for some records and other records were managed and monitored at head office. Access to information was difficult and it was not presented in a helpful way for monitoring performance and quality. This meant that the registered manager did not have a comprehensive overview of all aspects of the service provision and as a result governance was not as effective as required.

Staff told us they were well supported by the registered manager and they could raise concerns freely.

Feedback from health professionals was positive when discussing their interactions with the registered manager and staff within the home.

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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people.

Feedback from staff on the culture and direction of the service was positive. Staff felt well supported and confident in the management of the service, direction of the service and support provided to ensure they could meet people's needs and give them the best outcomes they could achieve.

The quality assurance systems in place did not always support the development of the service to improve. Quality monitoring of staff supervision, training, care planning, risk assessments and daily records was not embedded or in some instances taking place at all. Some areas of governance were managed and monitored by head office and not by the registered manager. This meant the registered manager did not have full oversight of the service and what was needed to improve.

Comments we received from people’s relatives indicated that staff were not always knowledgeable about people’s needs, as for example with dementia. The provider did not have clear training records to alert them to where staff needed additional training such as with dementia.

The provider did not have clear training records to alert them of staff training needs.

Staff were complimentary of the registered manager and told us they received good support from them. Staff members told us they were able to speak with the registered manager whenever necessary but they said they did not have regular and formal 1:1 meetings with them. People’s relatives told us the registered manager provided themselves and people living at the home with opportunities to meet and discuss matters with them.

Under the previous provider feedback surveys were not frequently carried out, however the new provider was in the process of putting mechanisms in place for people using the service, their families, staff or visiting professionals.

People did not always feel they could speak up and that their voice would be heard.

There was no policy or processes for staff to feedback. The Provider has a whistleblowing policy; however, staff do not receive mandatory training on whistleblowing. It was not clear how the provider would support staff to speak up.

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.

There was an equality and diversity policy for staff. Staff told us they felt they were treated equally. The staff team observed during inspection was diverse. The organisation publishes their Gender Pay Gap report on their website. The registered manager told us additional hours are offered out to all staff at the same time via their rota system.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Staff told us they knew what was expected of them as they discussed this during team meetings and with their line managers.

Staff told us the management of the home was good. A member of staff said, “Yes, [registered manager] is available at all times. She listens to me, motivates and encourages me. I can approach the registered manager at any time and with any need.”

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 provider worked with other health and social care professionals but there was no evidence of shared clinical governance or learning from incidents. There was no feedback process or policies in place for partner agencies. The manager has told us they have started to put this in place.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Staff told us they would benefit from specific training to better meet the needs of people living in the home, in particular staff who did not have any prior experience in some areas of their work.

Staff told us they worked with each other and could seek guidance and support from experienced staff and the registered manager.

Staff and the management worked with health professionals for extra support and guidance to ensure people received the care needed.

The registered manager acknowledged staff without prior knowledge would gain better understanding with more specific and needs related training.