44 Albion 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

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

The service was in breach of legal regulation in relation to good governance.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Whilst the provider had a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement, this was not reflected at the service and location level. Where they did not always understand the challenges and the needs of people and their communities

The provider had a vision and strategy for the organisation and its services. However, the service did not always operate in line with these values. The recent failure to consult with people, relatives and staff before resettling people resulted in significant and on-going upheaval at the service. The incompatibility of people arising from this inappropriate resettlement, and the discontentment experienced within the staff team, meant that people’s needs could not be met in line with the provider’s vision.

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.

Leaders did not demonstrate knowledge, compassion or skills during the most recent transition to the service. One person was supported to move into the service with needs which had a negative impact on the well-being of people already living at the service. The provider acknowledged that the placement had been unsuccessful and was working in partnership with others to identify what went wrong and to stabilise the situation. However, a safe transition for this person to a new service, where their needs could be met, had still not taken place at the time of our on-site assessment. This meant that care and support was provided reactively to manage risks to people’s well-being rather than proactively to provide person centred care.

The registered manager supported staff with debrief meetings following incidents. Debriefs were meetings at which staff could talk about events that occurred, the feelings they evoked and the support they required. Staff had access to a confidential helpline to access counselling if needed.

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

People, relatives and staff did not always feel listened to. Staff were concerned that the compatibility of people had not been discussed before a person recently resettled to the service. One member of staff told us, “Residents should have been consulted.” A second member of staff said, “Compatibility is an issue” adding that because of the transition, people, “aren’t a good mix.” Whilst the provider arranged meetings with staff and organised surveys of them, this still meant that the views of people and staff were not always sought and acted upon regarding matters that directly affected them.

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.

People were supported by a diverse staff team, reflecting the diversity of the people living at the service. This enabled staff to readily identify and meet people’s cultural needs and preferences.

Staff told us that the registered manager and provider treated staff equally and had not observed discrimination.

Whilst the provider organisation had clear responsibilities, roles and systems of accountability, this did not translate into good governance for the service.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 systems for assessing, monitoring and mitigating risk had not been effectively implemented. People were placed at risk because of the incompatibility of the group living at the home. The provider had not consulted with people or their representatives when making decisions that affected them. Staff also told us they had not been consulted during this process. This meant the provider had not fully assessed, monitored or improved the quality of people’s lives and experience.

The service had a new registered manager in post who was clear about their role. The registered manager audited the quality of the service and was supported to do this by the head of area and the provider’s quality monitoring staff. Quality checks covered a range of areas including health and safety, care records, staff training and the environment. Where shortfalls were identified, action was taken. Quality audits were monitored by the provider organisation to ensure that plans were followed through to satisfactory completion.

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 other organisations to meet people’s needs. For example, following referrals to health and social care professionals, staff supported them to undertake assessments, implemented their guidance and provided feedback for reviews.

People engaged in their local community. Staff supported people to participate in a range of activities. These included using local facilities such as shops, eateries and gyms.

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 did not always focus on timely learning to improve outcomes at the service. Whilst staff had the opportunity to familiarise themselves with the assessment of one person before they moved into the service, not all staff received training to meet their specific needs before their arrival. This negatively impacted the confidence of staff around supporting people’s anxiety and distress. In addition, the provider’s ability to improve the experience and outcomes for people was restricted by the dynamics caused by the incompatible mix of people.