Alexander Court

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.

This is the first assessment for this service under a new provider. This key question has been rated 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 good governance of the service.

This service scored 61 (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 and their communities.

The service had gone through a recent transfer of ownership. Some staff told us that the change in ownership had been challenging due to new systems. One staff member told us, “It was a new company, new ways of doing things.” However, we found team meetings were not held regularly and found little evidence in the staff meeting minutes on supporting the direction and vision of the service.

The leadership were working on strengthening systems and processes were being implemented.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

The leadership team failed to demonstrate effective oversight of their responsibilities. For example, they failed to act on environmental risks including a broken front door, ensuring care plans were reflective of people’s current needs regarding diabetes, and ensuring action was taken when people did not consecutively reach their daily fluid targets.

However, the leadership team were proactive when we raised our concerns, and these had been actioned or were being actioned by the end of our inspection.

A relative told us, “Things seem to be getting better with the new manager.”

The manager’s application was in process for Registered Manager with CQC.

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

The provider had a whistle blowing policy in place and staff we spoke with felt confident to talk to the leadership team of the service. One staff member told us, “It’s easy to raise concerns, the manager is very approachable and tries to help us.”

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.

All staff completed equality and diversity training and understood the importance of treating colleagues and people with respect.

There were no reports of bullying or discrimination, staff said they felt valued and supported.

The provider did not have effective governance systems in place to assure themselves of the quality and safety of care provided to people. Audit and quality assurance of key areas of service provision did not identify concerns we found during the assessment. This meant issues were not always followed up, rectified and monitored appropriately to drive continuous improvements.

We found concerns in areas of reporting to safeguarding, medicine management, safe care and the environment. People were potentially being placed at risk. We did not find any harm had been caused to people.

The provider responded promptly when issues were brought to their attention and provided evidence of improvements made.

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. There was evidence that the service worked with local GP’s, pharmacist, social workers and other healthcare professionals.

The manager told us that the service was building links with the local community.

The provider did not always focus on continuous learning, innovation and improvement. The provider’s service development plan confirmed the implementation of a new reporting system for audits, policies and governance. We found governance processes had not led to improvement, for example concerns relating to the environment, care documentation and not reporting safeguarding concerns.

The service held daily flash meetings, which not all staff attended. We found team meetings were not held regularly, the meeting minutes we reviewed did not evidence lessons learnt. Some of the staff we spoke with were not aware of other meetings apart from the daily flash meetings. One staff member told us, “We used to have meetings every month, not now.”

Further work was needed to establish a consistent culture of learning, improvement and innovation.