Astley Hall Care Home

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.

During this assessment we identified a breach of regulation relating to governance.

This service scored 50 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. The day to day management did not always understand the challenges and the needs of people and their communities.

The provider had a clear vision and strategy, and these supported by relevant policies and procedures. Staff understood their role and knew what was expected of them. However, the day to day management and implementation of these values required further embedding. People and their relatives shared their experiences which was not always consistent with the provider’s expectation. Staff described how staffing levels, communication and management support impacted on their ability to do the job well. This indicated the daily management oversight was not always effective or responsive. The regional manager responded positively to our feedback and immediately began introducing changes to address issues, improve safety and quality of care and shared learning with staff to prevent recurrence. This includes performance management processes used to better understanding of expectations and foster accountability across management and staff team.

Staff spoke positively about team working, and the direct support from their senior care staff, nurses and the clinical lead. Staff expressed being happy working at the care home and their comments included, “I love the human factor and making people's lives happier in their dementia journey” and “I enjoy my job because I want to do my best to care for people. I want to be able to practice nursing which I'm qualified to do as I've passed my exams.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The service had changes in managers which impacted on the consistency and effectiveness of leadership and oversight. We identified the need for the manager to have a greater level of oversight of the service, particularly in relation to people’s care and support, record keeping and staffing and staff deployment, and to ensure overall accountability.For instance, people and staff had mixed views about the different manager’s visibility and approachability. A staff member told us, “[Manager name] is lovely but they are still growing into the new role.”

We saw evidence of duty of candour in practice and an inclusive workplace culture. Mechanisms for gathering feedback were in place, including a resident ambassador and resident and relatives’ meetings. The manager, regional manager and provider had been open about areas for development, strengthening the management team, challenges, and the resources needed to achieve their plans. The manager was supported by clinical lead and a newly appointed deputy manager and a business support manager. The regional manager was supporting the manager to develop into the role, and to fully understand their responsibilities. The manager had submitted an application to CQC to be registered.

People did not always feel they could speak up and that their voice would be heard.

A range of mechanisms were in place to enable people, relatives and staff to speak up. People told us they would speak with specific staff and that they would be listened to. Systems to support staff included supervisions, meetings and the whistleblowing procedure. One staff member told us, “I had supervision for not making the bed properly and was shown how to make the bed; now I'm fine making beds. Usually we only have group supervisions.” Staff told us they did not always feel comfortable to discuss personal goals and development opportunities in group supervisions. The staff team felt supported by their colleagues and all were committed and compassionate about caring for the people in residence. Staff knew how to access additional confidential support. Staff told us they were not always confident or encouraged to speak up. For instance, staff felt their concerns about staffing levels were not listened to. The regional manager assured us action was being taken to support and empower staff to speak up without fear.

The provider valued diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had systems, procedures and training in place to promote equality and inclusion within the workforce. A staff member told us, “There is a cultural difference and staff accents can be difficult to understand but they are so caring and wanting to help residents.” We saw respectful interactions and good communication between staff of different backgrounds, and staff said they worked well as a team.

Staff told us they had not experienced bullyingand harassment, and felt they were treated equally with regards to their protected characteristics for instance flexible working patterns and privacy to observe their faith. Some staff described a lack of recognition and opportunity to develop had impacted on their wellbeing. When staff had requested changes to their contractual hours, the management had not always supported this. We discussed this with the regional manager and they assured us action was being taken to improve staff wellbeing and promote equality of opportunity. This included a career progression role to a care practitioner with additional training and responsibilities, which suited some staff completing a nursing qualification.

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 outcomes, or share this securely with others when appropriate.

The provider’s oversight governance and monitoring systems were not used effectively to ensure safe practice. The issues we identified during this inspection had not been identified by the day to day management. There was a lack of oversight and scrutiny in relation to people’s care needs, monitoring risks, medicines, staffing levels, and leadership. For example, there was insufficient oversight of staffing despite concerns being raised by staff, people, relatives and external agencies. A sample of the audits completed were not accurate and where shortfalls had been identified there was no plan of action in place. Further action and scrutiny was needed to improve call bell monitoring to ensure staff responded promptly.

The provider’s internal quality and compliance audits scrutinised information and monitored the progress of improvement. The regional manager had already identified areas for improvement and was at the early stage of implementing changes to address the issues that had been found. They also assured us the management team had access to resources and external support as required.

Commissioners with responsibility to monitor the safety and quality of care for the people they support had carried out monitoring visits in January and April 2025. They identified similar concerns to what we found. Whilst some improvements were found, other actions still in progress.

Feedback from people, their relatives and staff had mixed experiences and felt their concerns were not always acted on by management. Some action was taken by the regional manager immediately. An action plan was put in place with target date for compliance and named personnel with responsibility to make the improvements.

The provider did understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did share information and learning with partners or collaborate for improvement.

People and relatives told us staff were available most of the time. We observed good communication between people and staff. The service also maintains strong partnerships with external organisations. People had been referred to external health and social care professionals when required. A visiting health professional told us there had been concerns previously and said, “It’s a much better place now.”
 

People were supported to access the community. A person told us their interests and hobbies, and told us about their holiday planned later this year, and were looking forward to. The service has aresident ambassador with an active role in welcoming visitors, providing information and assisting with queries from people, their relatives and supporting staff. A relative said, “Whenever I come here, it's so welcoming and I'm always greeted with a smile and staff are willing to listen to me.” The resident ambassador was involved in gathering people’s views and this promoted a culture of inclusion and person-centred care.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. Opportunities to deliver equality of experience, outcome and quality of life for people were not fully embedded to actively contribute to safe, effective practice and research.

The provider was committed to continuous learning and improving the quality of provision, however the lack of effective leadership and oversight meant opportunities were missed. For instance, concerns raised by people, relatives, staff and also identified by commissioners in relation to people’s care and staffing were still observed during this inspection visit. The manager and regional manager accepted improvements were needed and were responsive and shared the concerns with staff; setting out the improvements required. Lessons learnt from incidents, audits and feedback, required further embedding to improve consistency across the service.

The regional manager told us about the provider strategy on ‘living well’ and a focus to transform dementia care. This is at an early stage and showed the provider’s commitment to continuously innovate and develop the service.