Aylestone

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 our last assessment we rated this key question as good. At this assessment, the rating remains good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Processes were in place to promote equality and diversity for people and the staff team. The provider’s statement of purpose clearly set out their values. Staff demonstrated they understood the provider’s values and the provider’s representative maintained good oversight to ensure values were embedded in the care provided.

The provider’s representative had a good understanding of the service and culture of the staff and the service. However, there was no registered manager in place, the registered manager had recently left the home, and the provider told us they were in the process of recruiting to this position. A temporary manager was overseeing the service who was also registered at another location. This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. There had been 4 registered managers at the home since our last inspection which had impacted on the consistency of how the service was managed.

Relatives expressed some concern around inconsistency in leadership. Comments included, “When the management was stable, it was good and communication was great. Now, we are not sure who to go to and don’t know what’s going to happen. A lot of the staff who knew [Name] well have also left which doesn’t help” and “There has been no manager there for a few weeks and we haven’t been told what’s in place. There’s been quite a few managers over the years and a lot of new faces. We don’t know who staff are. It would be helpful to have better communication and a board of staff photos when we visit.” However, some relatives felt the interim management arrangements were working well. A relative told us, “The covering manager is good, they are on the ball. They know what’s good for {Name]”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had forums and processes where staff could raise concerns or make suggestions. We saw that management actively promoted staff to speak up to drive improvement. They encouraged staff to raise concerns, share ideas and learning and promoted the value of doing so. Staff were confident that their voices were heard. There was evidence to show managers investigated any concerns or issues sensitively and confidentially; lessons were shared and acted on. There was a whistleblowing policy in place and senior managers visited people and staff in services to have a visible presence and direct line of communication.

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. Managers encouraged teams to understand every team member’s diversity to promote tolerance and acceptance. The provider supported staff emotional and physical wellbeing which enabled individual staff to contribute equally in their roles. Staff told us they felt supported to give feedback and were treated equally, free from bullying or harassment. They told us they had access to relevant policies.

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, or share this securely with others when appropriate.

The provider had a range of governance systems and processes in place to monitor the quality and safety of the service. These included quality audits, regional quality assurance visits, quality improvement plans, management meetings, and training oversight. These arrangements supported managers to identify some risks and monitor key aspects of service delivery.

However, governance systems were not always effective in identifying, assessing and addressing concerns in a timely way. During the assessment, we found inconsistencies in record keeping and staff approaches and these issues had not been consistently identified through the provider’s existing quality assurance processes. Managers were aware of some of these concerns and acknowledged improvements were needed. They described plans to strengthen record keeping and address identified issues as part of wider organisational improvements. However, these actions had not been fully implemented or embedded at the time of the assessment.

There was no registered manager in post and, although a temporary home manager had been appointed, they were also responsible for a second service. This reduced management accountability during a period when the service was supporting people with complex needs who relied on staff having access to accurate, up-to-date information. Overall, governance arrangements had not consistently ensured the effective oversight of risks, records and the quality-of-care people received. The provider was aware of this and had increased senior management oversight in the interim period.

The provider understood and carried out 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. The leadership team had established good partnership working with various organisations and external stakeholders to provide positive outcomes for people. They knew who to contact if people required additional support from other healthcare professionals such as GPs, district nurses. People regularly went out locally and used local resources which helped to make them feel part of their community.

The provider strived to focus on continuous learning, innovation and improvement across the organisation and local system. The provider ensured lessons learnt were shared across their services. The provider was motivated to learn and improve the service for people. Although we found some concerns during this assessment, the provider was learning from shortfalls and had oversight of the service to enable prompt learning and identify where improvements were needed. This included improvements to the culture, working practices and leadership of the service, and being clear on the level of needs and compatibility the service was able to support. The provider’s representative was responsive during our inspection and told us what action they would be taking.