Alexandra Court Care Centre

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 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 requires improvement. At this assessment the rating has remained 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 and we requested an improvement plan from the provider.

This service scored 46 (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. The provider’s core values were clearly articulated and displayed on their website with the organisational vision defined as ‘Kindness is key’. Our observations in the care home and people’s experience highlighted inconsistencies in understanding these values at an operational staffing level which impacted on the quality of care and support provided.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively. At the time of the inspection there was limited confidence in the leadership and management in the care home. When we spoke to people and their families about the management team, the responses were mainly negative about the style of management and delivery of care. People told us members of the management team did not know or talk to people unless they were asked a question. A relative told us, “[I have] no idea who the manager is but there are always loads of people in the office.” Another relative told us, “My confidence in this care home is at rock bottom because of all the issues we have had.” The provider made us aware a new manager had been appointed and was on their corporate induction at the time of the inspection. There had been changes made to the wider management team to ensure effective support and improvement.

People did not always feel they could speak up and their voice would be heard. There was a whistle-blowing policy in place, however, there was not always a positive atmosphere in the care home where members of staff felt they could speak up. There were concerns about the consistency of leadership and management in the care home which impacted on people speaking up and sharing ideas.

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. The provider expected all their employees to be treated with respect. The provider aspired to provide a working environment in which all employees could realise their potential, free of harassment and discrimination.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Oversight and governance by the provider and the local management team was not effective. Regular management walkarounds, audits and quality checks were not completed consistently. The inconsistent approach to quality monitoring and governance resulted in poor oversight of care and support. There was not a culture of continuous improvement at the time of our inspection. The provider had developed new governance documents which were in the process of being implemented and reviewed. These new governance systems needed to be embedded, reviewed and sustained by the new management team.

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. However, this was identified as an area of further development and improvement. Feedback from external professionals raised some concerns about quality. The new management team needed to focus on developing strong relationships with key partners and local communities.

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. The provider had recognised their governance systems needed to be strengthened within the care home. New governance documentation had been developed and was being introduced and needed to be fully implemented, reviewed and embedded to ensure improvements were made.