Old Alresford Cottage

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 requires improvement. At this assessment the rating has remained requires improvement. This meant the service was not consistently managed effectively and well-led. There were some shortfalls in service leadership which did not always ensure the delivery of high-quality care. The service was in breach of legal regulation in relation to the governance of the service.

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.

Both leaders and staff spoke positively about the improvements which had been made. One leader told us, “I believe we are a good home, we have a good staff team, the care is really good, we are a lot more responsive than we were.” The service had a shared vision, strategy and culture. Leaders spoke of the positive culture which had been developed within the service. Both leaders and staff described a highly personalised and caring approach when supporting people. Staff worked well together with a shared people centred focus. The leadership team told us they worked well together, and their skill set complimented each other. Staff mostly confirmed the management team were available and supportive. One staff member spoke of the positive culture within the service saying, “Any concerns, I would raise them, I do love it here, every day is different.”

Policies were in place to help ensure equality and diversity were promoted. People’s protected characteristics were valued and did not act as a barrier to accessing the care and support they needed. The diversity of the staff team was also valued and promoted. Staff knew people well and the workforce was stable enabling the culture to become embedded and understood well by staff. Staff attended meetings. There was some evidence that these were used to encourage staff to share ideas about how the service might improve.

Staff confirmed there had been leadership changes following our previous inspection. Staff were mostly positive about the registered manager, deputy manager and senior care staff, describing them as approachable. They were confident that immediate action would be taken when any concerns about people or practice were to be raised. Leaders were committed to developing staff to become future leaders, recognising their skills and commitment to providing the best care. The leadership team were visible within the service and the deputy manager worked alongside staff, adopting a hands-on approach to the care and support of people, but also to ensure that the quality of care was being maintained.

The service had a clear commitment to providing person centred care and valuing people who lived at the home and the staff team. A number of the day to day management and leadership functions were delegated to the heads of care and team leaders. The leadership team told us the senior staff were skilled, knowledgeable and they were confident in their competency to undertake these functions. These staff had completed additional qualifications in health and social care and leadership. Senior care staff were able to describe how they mitigated and managed some risks, however the leaders were not always aware of all risks identified and action taken by senior care staff. This meant the current delegation arrangements were not always effective. For example, audits which had been delegated to other staff had not always been reviewed by the management team. Such as the medicines audits.

Systems were in place for staff to raise concerns. Staff mostly told us they were comfortable approaching any of the leadership team to raise concerns and were confident they would be listened to and action taken in response. Leaders demonstrated their understanding of their responsibility to act in accordance with the duty of candour.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The service had systems and processes in place to enable people and staff to speak up. For example, daily handover meetings, regular staff meetings, supervisions meetings, resident meetings and surveys. We saw evidence of information posters on display for both people and staff in relation to how to raise concerns, both internally within the organisation, and externally to other agencies, such as CQC.

Staff felt they were treated equally. Staff mostly felt supported by the leadership team and felt they received good support from colleagues. Staff shared examples of how they had been supported to develop their skills and progress their career.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. Leaders identified if staff needed any additional support and responded flexibly. The provider’s systems and processes supported this.

The service expressed a commitment to quality improvement. Leaders told us they had implemented a lot of changes since the last inspection which they felt had improved the service significantly. They acknowledged improvements were still in the process of being made but told us they believed they had the right management team in place with a motivated and competent staff team. However, whilst the leaders were aware of some the concerns we had found during this assessment, we found they had not always been aware of all the concerns. For example, when we sought clarification around a person’s PRN protocols not being followed, there was conflicting information from staff and leaders. When our concerns relating to the accuracy and robustness of records were discussed, they started to take action to address this during the assessment.

Governance arrangements were in place, but these were still not always operated effectively. Audits were completed but failed to identify all of the concerns we found during our assessment. For example, where sufficient risk assessments were not in place to mitigate risks to people, where people’s ‘as required’ medicines protocols had not been followed and the gaps we found in recruitment files and medicines administration records. Whilst the provider had identified a concern in relation to records and lack of detail, their systems and processes had not identified the extent of the concerns we had identified during the assessment. For example, mental capacity assessments and best interests records. The provider could therefore not be assured that all areas of service delivery were being adequately monitored and that robust action would always be taken to make improvements.

People and their relative’s confirmed people were supported to access health and social care professionals as they needed and were supported to ensure all relevant information was shared to promote the best outcomes for people and improve people’s quality of life. We observed 1 person being supported to register with a healthcare service of their choosing.

Staff and leaders mostly understood their duty to collaborate and work in partnership, so services work seamlessly for people. Both leaders and staff shared examples which illustrated partnership working with other external agencies and professionals. These examples demonstrated how people had benefited from this partnership working, especially in relation to health-related outcomes.

The feedback we received from health and social care professionals indicated that staff and leaders understood the importance of working in partnership with other professionals to ensure effective sharing of information about people’s needs, but also to promote learning and improvement. One professional told us, the leadership team were “All engaged and provided information as requested.”

The service mostly understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement. Strong relationships had been formed with the local community. The home had encouraged connections with people in the local community who had been identified as at risk of social isolation and loneliness.

Leaders spoke passionately about the need for continuous learning to drive improvements for the service. They described a strong ethos for continuous learning and improvement and shared their plans to continue improving the service. However, their systems and processes were not always operated effectively to support this ethos. For example, when examples were shared about learning which the service had identified, we found this learning was not as robust as it could have been and so the learning was not as effective as it could have been. Such as in relation to the investigation of accidents, incidents and complaints or in relation to the learning from reviewing records for accidents and incidents. Whilst we did identify shortfalls during this assessment, the provider was responsive and took action to address key areas of improvement.

The provider had taken some learning from our previous inspection as they had made some improvements to the service since our last inspection. For example, in relation to the environment. However, overall, not enough improvement had been made. Although the provider had systems and processes in place to identify actions to drive improvement, they were not always effective. For example, some audits lacked detail, and it was not clear what action had been taken to improve the service. Where actions had been identified as having been completed, we continued to find concerns relating to those actions during this assessment. The actions appeared not to have become embedded within the service. For example, an audit in June 2024 identified as an action to ensure all the ‘as required’ medicines medication sheets were up to date. At this assessment we found there were not ‘as required’ protocols in place for all ‘as required’ medicines. There was a system in place to investigate and respond to complaints and concerns. Whilst we could see complaints had been responded to, due to a lack of detail, it was not always clear how the outcome of the investigation into the complaint had been reached. There were systems and processes to promote opportunities for learning across the organisation and local system. For example, there was a weekly manager meeting to enable leaders across the organisation to meet and share best practice and learning. The leader attended external events which enabled them to network and develop the practice and approaches used within the service. For example, the leaders planned to attend a care home virtual event which would support them to prepare people and the service for the winter season.