Adalah Residential Rest Home Limited

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 the last inspection this key question was rated good. At this assessment this key question has changed to requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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.

The registered manager was visible within the service. Staff told us they felt supported by the registered manager. One member of staff told us, “I really like the team and the manager. The manager is very supportive and has a bond with the residents and knows how to support them.” Another staff member told us, “I like working here because of how much support I receive. There is a lot of understanding and commitment between the manager and staff.”

The registered manager was clear about their roles and had the skills, knowledge and experience to perform their role. The registered manager told us the provider had recently appointed an Area Manager to support with the running of the service. The registered manager felt supported by the provider. However, we found limited evidence to show the provider had carried out robust audits and processes.

Staff told us they felt confident to raise any issues with the registered manager and felt these would be addressed. One member of staff said, “The manager is very friendly and easy to talk to. We talk about mistakes if something goes wrong, we have a meeting to discuss and learn. We can always go straight to the manager whenever we have any problems."

The registered manager has policy and processes for staff to follow on ‘whistle blowing’. Staff meetings were being held regularly. We reviewed minutes and saw they included information about the service as well as reminders about training, staff rota’s, safeguarding and PPE. However, there were no action plans completed to evidence how issues raised were to be addressed, dates to be achieved and if actions had been resolved or remained outstanding. The registered manager sent surveys to people using the service to gather feedback about the service and discussed feedback with people who used the service. However, there was no formal record of discussions that took place following the survey. The registered manager told us they carried out regular resident meetings and we saw evidence of this. However, results were not always analysed for themes or trends.

Staff told us they had supervisions, but these were not completed regularly. A staff member told us, “I can’t remember the last time I had one, but I have had a supervision. It would be useful to regularly meet with management to discuss any concerns we have on a one-to-one basis.” Staff told us they had an induction when they first started.

The quality assurance and governance arrangements in place were not always effective in identifying shortfalls at the service. Risks to people’s safety and wellbeing were not always being recorded, monitored and managed effectively. There was no systems in place to ensure staff recruitment files, inductions, care plans and risk assessments were audited to ensure these were in line with regulatory requirements. This meant effective auditing arrangements were not in place to assess, monitor and improve the quality and safety of the service provided and lessons learned. There was no formal record for how the registered manager learnt from lessons following incidents. The service did not have a service improvement plan in place. A service improvement plan includes checklists and examples that help identify the necessary actions for enhancement and aid in developing an action plan to implement the required changes. Effective systems to monitor and improve the quality of the service were not in place. This was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.