Adel Grange Residential 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.

The service was in breach of legal regulation in relation to ensure everyone receiving care had a detailed care plan and monitoring the quality of the service.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Provider systems and processes designed to monitor the quality of the care was not always effective.

Leaders did not recognise gaps in their governance and monitoring systems. We found the learning and improvement culture was not robust and embedded to make sure all risks were managed and minimised, such as falls risks, medication risks and up to date accessible care plans. However, leaders had a positive relationship with staff, relatives and people living at the service. One member of staff told us, “The manager is very good and fair. I have a good relationship with them.”

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.

Leaders did not always ensure mandatory safety checks were completed. We found emergency evacuation plans which were used in the event of a fire were not kept up to date. We also found essential safety checks such as fire drills were not routinely completed. One member of staff told us, “I cannot remember the last time I completed a fire drill.” We found leaders did not have an awareness of the missed safety checks and audits were not successful in identifying this.

Staff lacked knowledge on when to speak up. We found some staff had a strong knowledge on essential subjects such as safeguarding, whilst other staff lacked a basic understanding of this. While staff told us they would raise concerns with the manager, some staff were unable to explain what they would raise or give an example of a time they may need to raise a concern

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 did not experience discrimination. We found staff were recruited safely and without discrimination. All of the staff we spoke with told us they had not observed any form of discrimination and this would not be tolerated in any form. One member of staff told us, “The manager treats everyone fairly. They are very good.”

The provider did not always have clear responsibilities, roles, 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.

Checks by leaders did not always identify short falls. While the registered manager did audits, spot checks and staff supervisions on a regular basis, these had not identified some of the issues regarding medication management, fire safety, lack of staff knowledge and missing risk assessments. The registered manager told us how they plan to improve their systems to minimise this happening again.

The provider was in breach of the legal regulation relating to the monitoring of safety checks being completed.

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.

Leaders and staff worked as part of their local community. Leaders at the service were up to date with local and regional changes and worked with local groups to ensure people living at the service had a good quality of life.

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.

Learning had not been embedded where people were at risk of incidents happening again. Short falls in medication had been found on an audit prior to the inspection and the audit identified the issue had been fixed. We found this had not been fixed for everyone when we completed our inspection. We found there were missing or partly completed care plans for 2 people on short stays, which meant staff didn’t have sufficient information to be able to provide safe care for these people.