Albert Road

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 remained 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.

Staff described a shared commitment to person-centred care, rehabilitation and promoting safety whilst enabling people to take positive risks. Staff demonstrated an understanding of people's individual goals, preferences and support needs, and were able to explain how the values of the service influenced day-to-day care delivery. Family feedback was also positive and reflected a culture in which people were treated with dignity, compassion and respect.

The provider encouraged staff to report incidents, safeguarding concerns and near misses, and there was evidence that incidents were discussed through supervision, team meetings, governance processes and debrief arrangements. Staff told us they felt able to raise concerns and seek support from managers when required. Leaders promoted openness and demonstrated a willingness to reflect on practice when things went wrong.
 

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders demonstrated a good understanding of people’s needs, the challenges facing the service and the risks requiring oversight. The Registered Manager was knowledgeable about individual people, safeguarding concerns, incidents and operational matters affecting the service. Staff consistently described managers as approachable, supportive and available for advice and guidance. Leaders engaged openly, provided information when requested and demonstrated a willingness to reflect on findings and identify opportunities for improvement.

Leadership arrangements supported the ongoing operation of the service through governance meetings, safeguarding reviews, audits and quality assurance processes. Leaders were able to demonstrate oversight of key risks and had implemented actions following incidents and safeguarding concerns. The provider had also introduced further developments to strengthen risk management and organisational learning during the assessment.
 

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

The provider had arrangements in place to support staff in raising concerns and reporting safety issues. Staff demonstrated a clear understanding of safeguarding responsibilities, incident reporting processes and escalation arrangements. Staff told us they would feel confident raising concerns with managers and believed concerns would be listened to and acted upon. Staff also demonstrated awareness of whistleblowing processes and understood how concerns could be escalated externally if required.

Systems were available to record incidents, concerns and safeguarding matters, and there was evidence that information raised by staff was reviewed. Team meetings, debriefs and organisational communication systems were used to share learning and reinforce expectations. Staff generally described a supportive working environment where questions could be asked and concerns discussed openly.
 

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 supported within their roles and generally described a positive team culture. Leaders promoted fair treatment and provided access to supervision, training and opportunities for discussion through team meetings and debrief sessions.

Staff reported that managers were approachable and supportive, and said they felt able to raise concerns, seek guidance and discuss issues affecting their work. Leaders encouraged open communication and created opportunities for staff to contribute ideas, reflect on practice and participate in discussions about the service.
 

The provider did not always have systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes.

Some records and monitoring information required further clarification, collation or retrieval from multiple systems before assurance could be obtained. This reduced assurance regarding the accessibility, consistency and effectiveness of information used to support governance and oversight.

Leaders used information from audits, incidents, safeguarding concerns and quality monitoring processes to identify risks and areas requiring improvement. Where concerns were identified, these were shared with relevant partner organisations, including the local authority, and healthcare professionals, to support risk management and coordinated action. However, the provider was less able to demonstrate how performance and outcome information was routinely used to evaluate effectiveness and measure improvement over time.

Improvements had been introduced under successive leaders and governance arrangements were capable of identifying concerns. Leadership arrangements were subject to ongoing change at the time of assessment, including interim management arrangements and recruitment activity. Whilst governance systems remained in place, the provider was less able to demonstrate through contemporaneous evidence how some improvements had been evaluated and evidenced as producing sustained improvements over time.

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.

The provider worked collaboratively with a range of external organisations to support people living at Albert Road. Records demonstrated ongoing engagement with healthcare professionals, local authorities, safeguarding teams, commissioners and other agencies involved in people's care and support.

The service worked with external partners when managing safeguarding concerns, incidents and complex risks. Appropriate referrals were made where required, and records evidenced involvement from safeguarding authorities, healthcare professionals, social workers and police services. This supported coordinated responses and helped promote continuity of care.
 

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

Learning actions were not consistently reflected in practice. Whilst lessons learned were communicated through debriefs, meetings and organisational communication systems, implementation was variable in some areas and evidence of long-term effectiveness was not always apparent. Although there were examples of improvement activity and outcome-focused reviews, much of the strongest evidence related to interventions introduced shortly before or during the assessment period and had not been established long enough to demonstrate sustained effectiveness over time.

There was limited evidence that staff and managers were supported through structured improvement arrangements that consistently demonstrated how ideas, learning and actions were translated into measurable service improvements. However, concerns were identified and actions were implemented.

Leaders demonstrated a willingness to improve and had recognised areas requiring further development. The provider had already begun introducing revised risk-management processes, enhanced governance arrangements and new frameworks intended to strengthen oversight of intervention effectiveness and organisational learning identified during the assessment.