Albany House - Tisbury

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

We reviewed 7 quality statements for this key question. Leaders had not fulfilled their responsibility to ensure a safe service, putting people at risk of harm. Insufficient action had been taken to address identified shortfalls and there was a lack of management oversight. Auditing had not been undertaken, so shortfalls were not being identified or addressed. There were no written action plans to keep any required actions under review. However, people’s rights were promoted and there was a supportive culture. There was positive feedback about leaders and the support they gave staff. Values and visions of the service were discussed and adopted by staff. People and their relatives were encouraged to give their views about the service, but there was not a formal system to promote this.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders promoted people’s rights. They said they aimed to ensure each person was confident to make their own decisions and live their life as they chose. They said it was important for people to maintain their interests and continue to be part of the local community. Leaders told us they also tried to bring the community into the home. This included visiting clergy, decorating the home for Halloween and giving sweets to local children who were ‘trick or treating’. Staff confirmed this. They said people were encouraged make their room as homely as possible and follow their preferred routines.

There were systems to ensure the values and visions of the service were shared and adopted by staff. Leaders were very involved in the service on a day-to-day basis and worked with people and staff on a regular basis. This enabled discussions and role modelling to occur. The home was homely, and people were encouraged to personalise their bedroom. The ethos of the service was discussed and promoted during the person’s initial assessment and regularly thereafter within care delivery.

Staff spoke highly of the management team. They said they were ‘supportive,’ ‘amazing’ and ‘brilliant’. One staff member said, ‘[Name of leader] is the best manager I’ve ever had.’ Staff told us morale was good, and leaders helped out where they could. Leaders confirmed this and said they liked to lead by example. They said they spent time talking and working alongside the staff team, so they could understand any challenges they were experiencing. Leaders told us they were aware they were behind with formal staff supervision sessions but spoke to staff regularly on a day-to-day basis.

Formal staff support and supervision systems were not established and sessions were infrequent. There were many ad hoc discussions, but these did not cover a specific format and records were not maintained. This did not ensure the ongoing development and wellbeing of staff. Staff meetings took place but not on a regular basis. Handovers were undertaken between each shift to ensure all staff were up to date with any information they needed to know.

Staff told us they would raise any concerns they had with leaders. They were confident they would be listened to, and appropriate action would be taken. However, staff told us they would contact other members of the management team or senior leaders if this was not the case. Leaders confirmed staff were good at raising anything they were not happy about. They said they aimed to be approachable and spent a lot of time in the home, away from their office. This enabled people to raise anything of concern more easily.

There was a speaking up policy and records showed action had been taken to ensure a satisfactory outcome to those concerns raised. However, formal systems to encourage people and their relatives to give feedback about the service, were not effective. ‘Resident and relative’ meetings were not held, and there were no records to demonstrate other forms of engagement. Leaders told us they used to hold meetings and send out surveys to gain feedback, but participation was poor. They said they were planning to investigate alternative ways to gain people’s views but had not yet actioned this. Records showed staff had been asked to share their views about the service, but the findings had not been coordinated.

Leaders and staff told us they were supportive of equality, diversity and inclusion. However, they recognised people, the staff team and local community were not very diverse. One staff member told us about diversity in terms of different religions people followed and the various ages and backgrounds of staff. They said any additional cultural needs would be researched, and discussions held with the person and their family and friends before an admission to the home. This would ensure the person’s needs could be met effectively.

There was a supportive culture and people’s individuality was promoted. Equality and Diversity training was mandatory for staff and a policy provided additional guidance.

Leaders told us they knew they were behind with their auditing and all management systems such as staff supervision and general record keeping. They said they knew what needed to be done but had not had time, due to other demands within the service. This included helping the care staff as needed, trying to cover the working roster and working in the kitchen if there was a staff shortage. Leaders told us they knew there were aspects of the environment, which required attention. However, they could only authorise small monetary works as all higher expenditure had to be authorised by the provider. This had at times caused delays. Staff told us they undertook some audits of the environment and the safe management of medicines. However, the shortfalls identified were not always addressed.

Leaders had not fulfilled their responsibility to ensure a safe service. Leaders had not taken action to address fire safety work required by the Fire Officer or electrical works identified by external contractors. Leaders were aware of the problems with the heating and hot water systems, but whilst taking remedial action, they did not address the route cause. This left some people cold and at risk of scalding. Leaders were aware this was unacceptable but told us they were restricted in the action they could take, as senior leaders had to authorise funding for large expenditures such as this. After raising our concern, senior leaders authorised the works and action was taken. Arrangements had been made for the fire safety works, a new water tank was installed, and electrical works were commencing. There was a lack of management oversight and auditing had lapsed. This included key areas such as risk management, staff training and the environment. The lack of auditing meant shortfalls were not being identified or addressed, and leaders could not be assured of safety or compliance with regulation. Leaders did not have any written action plans, which did not ensure improvements to the service were being monitored. We were told senior leaders regularly visited the service but did not formally undertake any audits or provide a written report. At the time of the inspection, the provider was away but had not left any contact details. This did not provide support to the management team or enable them to be contacted in the event of an emergency.

People told us they received good support from health and social care professionals as needed. There was also contact with church representatives and local community groups. Relatives confirmed this. They said the service was at the centre of the community and well supported by local people and professionals.

Leaders told us the service was at the heart of the local community and therefore good relationships had been established. This included the local surgery, whereby the GPs and district nurses had visited the home for many years. This consistency had enabled professionals to gain a good understanding of people’s needs and build relationships with individuals and their relatives. Leaders told us good relationships had also been built with specialist teams, such as care home liaison. This service provides mental health assessment and interventions to help people living in care homes.

Health and social care professionals told us they had established good working relationships with the home.

Care records demonstrated there was regular partnership working to meet people’s needs. Leaders told us there were also connections with contractors, training providers, suppliers and local community.

Leaders told us they were aware there were shortfalls in the service, and ongoing development was needed. They wanted to improve the environment for people and improve staffing levels, as this would enable them to focus more clearly on the management of the service, and day to day improvement. Leaders told us time and financial constraints restricted such development.

Audits were not identifying shortfalls in the service and there had been a lapse in staff training, supervision and gaining people’s views. These shortfalls did not ensure ongoing learning and improvement. Leaders did not have a plan to ensure the ongoing development of the service.