Archived: Alternative House Care Home Blackburn

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.

At the last inspection this key question was rated inadequate. At this assessment the rating has changed to 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 governance at the service. The provider had audits to monitor the quality and safety of the service, however these were not consistently effective. They did not always identify or address the concerns we found during this assessment. For example, in relation to managing risks to people, staffing, recruitment, medicines management, environment and infection prevention and control practices.

Feedback on the manager from people, relatives, staff and visiting health professionals was positive. Highlighting their knowledge and person centred interactions. Staff felt supported by the manager and provider praising the care and support they received.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We observed the manager, and staff promoted a positive culture, with people enjoying their company, and seeking to spend time with them. Staff understood equality and human rights, and this was reflected in our observations.

However not everyone felt the provider consistently promoted positive behaviours. One relative felt it was a breach of confidentiality and inappropriate for the provider to share information on social media. The provider took immediate action to anonymise their comments.

There was a lack of focus on driving improvements in the service. Not all areas of concern identified at previous inspections had been adequately addressed. There was a lack of clear action planning to drive the necessary improvements needed, and repeat concerns were noted at this inspection.

Staff felt supported by the manager, and provider. They said they were able to raise any issues or concerns as the registered manager had an ‘open door policy’. This meant staff at any time could speak with them. A member of staff said, “[Provider] is like my work Mum, she looks after us.”

The manager maintained a high level of visibility within the home, which gave them a high level of knowledge on the service, people, and staff issues. We observed the manager and deputy manager model behaviours that valued people and promoted a positive culture within the home.

Staff told us the management team were visible within the home and were confident they would listen to any concerns they raised.

Staff told us that management had driven improvement within the home and with their professional development. The provider had policies to support staff to speak up, raise concerns, drive improvement and keep people safe. However, evidence seen during our assessment showed processes weren’t being consistently followed effectively, as some relatives felt they were not always listened to by the provider.

Staff told us the provider valued them, and they worked together as a team and enjoyed working at the service.

The provider welcomed diversity in the workplace. Policies and procedures supported this. Relevant legislation and best practice guidance was implemented to ensure staff were treated in a fair and equitable manner. Recruitment processes supported fair employment opportunities.

The manager and deputy manager told us they had clear responsibilities, roles, systems of accountability that should deliver good governance. However, they said they did not always have time to complete all their audits and records, preferring to prioritise people’s support needs. This was reflected in the evidence we found during our visit.

There was a failure to have adequate oversight of staff training. The provider could not evidence all staff had completed appropriate training, and there was a lack of oversight to ensure staff had the suitable skills to fulfil their role.

Staff and the management team supported people to access key organisations for support with their care.

People and relatives told us staff assisted them in arranging support from other healthcare services as required.

People were supported to access additional health and social care through close working partnerships with external stakeholders. This ranged from district nurses, GP’s, hospital discharge teams to visiting entertainers.

The service worked in partnership with other agencies. These included healthcare services as well as local community resources. Records showed that staff had contacted a range of health and social care professionals. This enabled people’s health and wellbeing needs to be assessed so they received the appropriate support to meet their continued needs. The provider did not consistently share information with partners to collaborate on driving improvement.

Staff told us the manager would listen and act on their feedback to make improvements happen for people.



Leaders failed to evidence effective quality assurance systems, and how these were operated to ensure continuous improvement in the service.

Quality assurance systems were not adequate and did not evidence continuous improvement. Feedback from external partners was not effectively used to drive necessary improvements to the quality of care being delivered. The provider was unable to evidence any clear action taken in relation to feedback received. There were no mechanisms in place to measure the impact of any changes made to ensure they had the desired impact.