Alexander House

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.

We found the provider’s quality assurance checks failed to identify concerns around fire safety. The provider also failed to submit statutory safeguarding notifications to the CQC.

We found the provider was in breach of the legal regulation in relation to good governance.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. [LW1][AS2]

Feedback from people and relatives indicated there was a good culture within the service. A relative told us, “The care my [family member] receives is really good. They [staff] look after her well.” We reviewed some compliments that the provider had received praising the service for the quality of care provided.

Staff understood people had a right to be treated equally and fairly, and to receive care and support that met their specific needs. For example, staff confirmed people had the right to choose the gender of staff who provided their intimate personal care. We observed a male member of staff ask a female staff member to assist a person with their personal care in accordance with their wishes as stated in their care plan.

Staff were also aware of people’s diverse spiritual and cultural needs and wishes and knew how to protect them from discriminatory behaviours and practices. A relative told us, “The staff know my [family member] is a practising Muslim and therefore only eats Halal meat.” Care plans contained detailed information about people’s spiritual and cultural needs.

Staff expressed being generally happy working at the care home. One member of staff told us, “This is a good place to work”, while another added, “I like working here. The atmosphere is nice and the culture positive.”

The service provider gave new service users a service user guide and new staff members a staff handbook, which detailed the service's information, principles, and values.

[LW1]I believe the full standard statement for this QS is - 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.

[AS2]Yes , however the standard statement can be amended to suit.

The provider had leaders who understood the context in which they delivered care, treatment and support.

The services management team included the registered manager, a recently employed deputy manager and a senior team leader.

The feedback we received from people about how the service was managed was generally positive. People told us the managers were accessible and approachable.

Staff were also positive about the leadership approach of the managers who they consistently described as professional. One member of staff told us, “I think the manager [registered] is supportive and runs the home really well.” Another added, “I am confident in the manager [registered]. He’s always professional and you know who is in-charge.”
 

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

Managers encouraged a culture where people living in the care home, their relatives, external health and social care professionals and staff were encouraged to provide feedback.

People told us they felt comfortable raising concerns with the managers and felt listened to. A relative said, “The manager does listen to what we have to say. If you ask the managers to do something, they will.”

The provider used a range of methods to gather people’s views. This included regular meetings with people living in the care home, relatives and staff. A member of staff said, “We have regular supervision meetings with our line managers who ask us how we are and what we need to do the best job we can.”

The provider also held meetings with relatives and next of kins where they were provided with updates about the service and were also given an opportunity to ask questions.

Feedback surveys were completed by relatives and staff. The results of these indicated both staff and relatives were happy with the quality of service.
 

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 staff team were diverse and were provided support through relevant training and supervision to inform their knowledge and understanding of equality, inclusivity and fairness in the workplace.
 

The provider did not have clear 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's health and safety audit, conducted in December 2024 and January 2025, and the maintenance team's weekly fire checks both failed to identify the fire door issues and other environmental problems we found during our inspection.

The registered manager did not fully understand their responsibilities in relation to regulatory requirements around notifiable incidents. Our records indicated that, although they submitted some notifications, they failed to notify the CQC in timely manner about allegations of abuse that had been raised which they are legally required to. The provider had notified the local authorities of these allegations.

However, the registered manager and director held regular management teams to discuss any ongoing issues and areas of improvement for the service.

There was an audit schedule in place which was comprehensive in scope covering care plans, medicines, mealtime experience, checks on the environment and other areas.
Regular engagement with staff took place, including group and supervision meetings.

Spot checks took place to ensure people’s daily records, including medicine charts were being completed, staff were wearing the appropriate PPE and if people were settled.
 

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

Managers and staff told us they worked closely with various external health and social care professionals and bodies who they regularly consulted and welcomed their views and advice. An external health care professional remarked, “I feel supported by the manager [registered] and senior staff who run the care home and have regular meetings with them to find out how my clients are getting on.”
 

The provider focused on continuous learning across the organisation and local system. They encouraged ways of delivering equality of experience, outcome and quality of life for people.

Managers and staff recognised the importance of learning lessons and achieved this through reflective practice sessions with staff following any incidents and/or accidents.