Althorp Grange

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

Leaders were visible and approachable. However, there were shortfalls in leadership continuity, communication, and legal compliance. Frequent changes in ward management disrupted consistency, and staff expressed uncertainty about their roles during the hospital’s transition to a nursing home. There were gaps in leaders’ understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards, resulting in breaches of regulation. Governance systems had improved, learning from complaints was not robust, key audits were missing, and staff deployment remained inconsistent due to poor rota management. While Freedom to Speak Up structures were introduced and partnership working strengthened, the service continues to breach regulation in relation to governance and leadership oversight.

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. The service transition had impacted staff and produced new challenges for the provider.

The provider’s senior leadership team had not effectively communicated the organisation’s shared vision to frontline staff. This was due to a significant period of change, as the service transitioned from a hospital to a nursing home. The same issue was identified during the April 2024 inspection. Throughout the assessment, staff shared their concerns about the transition from hospital to nursing home, particularly regarding job security and role clarity.

The provider sent out a Broomhill hospital staff satisfaction survey in June 2025 with 120 surveys sent out and 87 returned (72% return rate). The June 2025 staff survey showed a generally positive workforce culture, with strong satisfaction in areas of training, support, and teamwork. Clearer communication, rota consistency, and regular supervision were the main areas for further focus. Wellbeing initiatives were valued, and morale was improving. An action plan was produced with timescales to complete by October 2025. The results were shared in team meetings, displayed in posters and in monthly governance newsletter. The next staff survey was due in December 2025.

Staff told us that the leadership team had not clearly communicated a structured plan regarding their roles during the transition period. The same issue was raised in the June 2025 staff survey and action taken by the provider included monthly newsletters, ward briefings, managers open-door weekly sessions. At the time of the assessment the provider agreed more needed to be done to ensure increased communication with individual staff and staff groups.

While leaders were visible and approachable, and staff remained committed to delivering person-centred care, there were shortfalls in communication and clarity around roles during the transition. Staff reported inconsistent leadership across wards, with frequent changes in ward management affecting continuity of care. There gaps remained in some leaders’ understanding and application of the Mental Capacity Act and Deprivation of Liberty Safeguards.

The new leadership team has been in place for less than 12 months. The provider had not supported managers to perform their roles effectively. The provider had not ensured continuity of care due to frequent changes in registered managers and ward management. This issue was also identified during the April 2024 inspection. Staff reported that ward managers were regularly moved between wards, and some wards operated without a dedicated ward manager. The management of staff rotas had not been effective. These changes disrupted consistency in leadership and negatively impacted patient continuity of people’s care.

Most leaders demonstrated an effective understanding of the services they managed and were able to articulate how their teams delivered high-quality care. However, leaders did not support one person in line with application of the Mental Capacity Act and Deprivation of Liberty Safeguards, which impacted compliance and oversight.

Leaders were visible in the service and approachable for people and staff. Staff told us the senior management team were often on wards including daily walk-arounds and offered visibility, reassurance and support.

Leadership development opportunities were available, including mentorship and support programs for new managers to aid staff retention.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

At the time of our assessment, we were not aware of any equality and diversity champions within the service. However, the provider had committed to developing these roles as part of its 2025–2028 ‘Equality, Diversity and Inclusion’ strategy. This included plans to grow staff networks for Black, Asian and Minority Ethnic (BAME) staff, LGBTQ+ staff, and staff with disabilities.

In the 2025–2028 ‘Equality, Diversity and Inclusion’ strategy the provider committed to equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group. Other actions for year one 2025-2026 to ensure 100% staff were trained Equality Diversity and Inclusion; managers in Inclusive Leadership; foundations for first diversity dashboards, pay gap report and pilot mentoring for under-represented groups.

Staff were able to apply to work flexibly to support personal circumstances such as caring responsibilities and health issues.

Managers put reasonable adjustments in place for staff members to help them carry out their roles.

The provider did not always have clear responsibilities roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcome.

Governance and leadership oversight still do not meet required standards. Although the providers approach to incident learning was well embedded, complaint investigation records revealed limited learning. The provider did not consistently identify recurring themes indicating a gap in governance and continuous improvement in this area.

The providers audits were sufficient to provide assurance and staff acted on the results when needed. However, the provider’s audit timetable did not include audits for the application of the Mental Capacity Act and Deprivation of Liberty Safeguard tracker. In addition, there were a shortfall around the management of Deprivation of Liberty for one patient.

Staffing deployment was inconsistent, and people did not always receive care when they needed it. Staff rotas were poorly managed, affecting consistency, and frequent changes in ward managers caused confusion. Regular therapeutic activities were cancelled due to staffing shortages which adversely affected individuals’ support with person-centred care, independence and progress towards recovery. We feedback to the provider about chaotic staffing levels during the assessment and they took limited action to make changes.

Medicines weren’t always managed safely, which could put people at risk. However, the provider was responsive to the medicine concerns identified during the assessment and take immediate action.

People’s risk assessments were not always completed consistently, with some risks had not been properly identified or managed.

Managers ligature audits were not complete, and some risks to people hadn’t been addressed. Some repairs and maintenance issues had not been fixed, which could affect people’s comfort and safety.

Some people did not receive care in the least restrictive way because the Mental Capacity Act wasn’t always followed. This led to delays and affected their dignity. The provider did not constantly demonstrate a good understanding of the Mental Capacity Act. This led to breaches of legal regulations

Staff were unclear about their roles during the hospital’s transition. The provider did not communicate effectively with staff during the hospital’s transition, leading to uncertainty that negatively impacted staff confidence and clarity about their roles and responsibilities.

The provider carried out a review of the governance framework from March 2025. Changes to the governance processes now included developing a safe culture of incident reporting, management, near misses, learning and practice improvement. Learning from all incidents including incidents through delivery of care, serious incidents, Section 42 investigations and other learning opportunities were identified at the daily morning meetings. A Section 42 investigation is a statutory inquiry by the local authority into suspected abuse or neglect of an adult with care and support needs, with learning shared through governance and staff briefings.

Managers maintained and had access to the risk register at ward or directorate level. Staff at ward level could escalate concerns when required. Staff concerns matched those on the risk register.

The service had business contingency plans for emergencies for example, adverse weather or a flu outbreak.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care.

Information governance systems included confidentiality of patient records.

Leaders had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Leaders reported improved collaboration with local integrated care boards (ICBs), local authorities, community mental health teams, and mental health trusts through monthly multi-agency partnership meetings. These meetings helped foster transparency and supported joint problem-solving.

People and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback.

The service 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.

Following the last inspection in April 2024, the provider was given time to embed improvements. We still found shortfalls in the provider’s action plans, particularly in relation to ensuring people’s dignity and respect, medicines optimisation; stabilising leadership; and embedding the provider’s new vision. However, the provider implemented initiatives to improve the following: the rehabilitation model of care; meeting people needs and involving people in their care planning, listening to staff and implementing the Freedom to Speak Up process.