Adeline House Care Home

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 good. 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. 

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. Some staff told us that staff morale was low at the moment due to the job being very demanding.

The provider had inclusive leaders who understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge, and experience to lead effectively. They did so with integrity, openness and honesty. The manager was in the process of registering with the Care Quality Commission. The manager was supported by a deputy manager and a team of nurses and senior care workers. Support was provided to the management team by the area manager who visited the home weekly. We received mixed comments about the management team from people and relatives.One relative said, “I have only seen the manager once. The difficulty is that I go on weekends and [the manager] doesn’t work weekends. When I have gone in the week I haven’t seen [the manager] walking around.” Another relative told us they, “Hadn’t seen anyone to speak to.” We spoke with the manager about these issues and were told systems were in place to obtain feedback. The deputy managers had started contacting families and scheduling quarterly reviews of care plans. A newsletter was also available to people and relatives which gave information and updates about the home.

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 and staff were supported to raise concerns and the manager was keen to listen to people and make changes. Staff were confident the management team would take appropriate actions swiftly to ensure people were protected from harm.

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. Policies and procedures incorporated all aspects of equality, diversity, fairness and protected characteristics. Staff felt the management team were approachable and felt included in service developments. One staff member said, “I feel listened to. Yes, we always talk things through and look at a different way, what would be the best choice.”

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. Governance systems were in place but required strengthening to ensure audits identified areas of improvement and actioned on in a timely way. The management team were in the process of making changes to improve the governance of the service. We found shortfalls throughout the quality statements we assessed. Issues we identified as part of this assessment had not always been previously identified or timely action taken to address them. For example, during our walk round we identified an unclean dining area with spilt vinegar and unlabelled/dated jams and spread. Thickener was also stored in an accessible cupboard. We also found some areas of the home required actions to ensure they were safe, such as assessing the risk of windows without restrictors and some radiators which had no covers. We raised these issues with the manager who took swift action to address them.

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 told us how they worked in partnership with other professionals to ensure people were included in their communities and had access to relevant services.

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. Quality assurance systems were not always effective and did not always identify areas for improvement. For example, accidents and incidents were recorded but not analysed to ensure trends and patterns were identified to mitigate future risks. This reduced opportunities for learning and improving care.