Allambie 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.

At our last inspection we rated this key question requires improvement. At this inspection the rating has remained 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 remained in breach of legal regulation in relation to 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.

Our inspection findings and staff feedback showed the provider had not considered the impact reducing staffing levels and assigning care staff to cover kitchen duties would have on the people living at the service. We saw 1 person walking in the upstairs corridor appearing confused and no staff were available to support them. Staff confirmed people at times did wait for support since the reduction in staffing.

A staff member told us, “One improvement would be more staff, it’s hard when we have to do dinners too.” Another staff member said, “At breakfast we lose 2 carers straight away. Then we have to do all the cleaning in the kitchen and sort the lunch. It’s hard.”

Current staffing levels had created additional work pressures resulting in the poor standards of cleanliness we found in some areas of the service. For example, the poor hygiene of the kitchen. In response to our feedback the provider increased the contracted hours for the domestic and revised their cleaning schedule. However, further consideration needs to be given on how to effectively deploy and allocate duties to ensure sufficient staffing levels are maintained to ensure people receive safe and timely support.

The provider had inclusive leaders; however, they did not always have the skills, knowledge and experience needed to ensure they maintained effective oversight of the service. Quality monitoring systems in place were not always effective, as they had failed to identify the issues we found. For example, fire safety concerns and potential ligature risk caused by some keys hanging down from a plastic, spring chain in a communal area.

While systems were in place to guide staff on the expectations of their role, responsibilities and tasks, many of those delegated tasks had not been completed effectively. We saw daily cleaning schedules had inaccurately reported compliance and did not escalate the issues we found for example, the poor standards of cleanliness in the kitchen. Governance systems and managerial oversight had failed to identify and address these issues to ensure the environment was safe prior to our inspection feedback.

People knew who the management team were. One person told us, “I have made complaints, and they have been dealt with straight away.” Another person said, “I have no complaints, if I did, I would tell the higher ups, and they would listen and do something.”

Staff told us they felt supported by the management team. One staff member said, “The manager is very good and really supportive. Well, both managers are very good.” Another staff member told us, “I do have supervision, but I don’t feel the need to wait for supervision if I’ve got a problem. The manager’s door is always open and at any time I can go and talk things through."

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

Staff felt confident to raise any issues or concerns with the management team if needed. One staff member told us, “I have never felt I couldn’t say what I thought. I will say if I think something isn’t right and if I think we could change things.” Another staff member said, “We have all been here a while, we a stable group and trust each other so you can share any worries or talk about making things better.”

The provider also held regular team meetings, where staff had the opportunity to raise concerns and offer suggestions. The registered manager understood the need to be open and honest when things went wrong in line with their responsibilities under the duty of candour.

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.

Staff told us they felt included in decisions about the service and enjoyed their job. One staff member told us, “The management are open to listening to your ideas.”

All staff had received equality and diversity training. The provider’s policies promoted equality and diversity, and a diverse staff team has been recruited to support people living at the service.

The provider did not always have clear responsibilities, roles, systems to manage effective governance and oversight of the service.

Daily ‘walkabouts’ completed by a member of the management team to monitor the safety and quality of the service provided were no longer documented. We were advised by the general manager they were still completed and any actions were discussed with staff in the daily ‘Safety Huddle’ meeting rather than documented separately. This change was introduced in October 2025, when asked, the operations manager confirmed the provider’s expectation was to complete and document the daily ‘walkaround’ which “should be tailored to your home."

We found quality audits and checks were not always effective as they failed to identify some of the issues we found. For example, gaps and damaged ceiling tiles in the laundry and a toilet door not closing properly into the rebate which posed fire safety risks.

During this inspection, we also found the dependency tool based on people’s individual care needs which is used to determine safe staffing levels had not been reviewed since June 2025. We shared our concerns regarding this and current staffing levels with the operations manager who agreed to review this.

This was a continued breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found some areas of improvement for example, care records for people’s clinical needs were detailed and regularly reviewed.

The registered manager demonstrated an understanding of the regulations and their responsibilities in relation to these. For example, they had informed us about important events within the service.

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.

Staff worked in partnership with health and social care professionals to ensure people had the best outcomes for their health and wellbeing. People and relatives confirmed this. One person said, “Staff check, to see if I’m okay.” They know what I like and what I don’t like. I’m allergic to a few things they listen to me and so they are no problems."

The provider did not always focus on continuous learning and improvement across the service. While some improvements were evident following our last inspection. These had not consistently been embedded into practice and further improvement was needed to ensure the provider was monitoring the service effectively and governance processes strengthened to ensure any action taken in response to safety and quality concerns were maintained.

The management team were responsive to our feedback and took some immediate action to address the concerns we identified during our visit.

Staff recorded incidents and accidents. These were reviewed by the registered manager and action taken to prevent reoccurrence. Any lessons learnt were discussed in team meetings.