Aberford Hall

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

At our last inspection we rated this key question requires improvement. At this assessment, the provider had improved, and this key question is now rated good. People, their relatives and staff all spoke positively about the registered manager. There was an open and inclusive culture and team working was evident. The service worked well in partnership with other agencies, where necessary, However, systems of audit were in place, but they were not always effective.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they were proud to work at Aberford Hall and many staff had been in place for a long time. They felt the manager led by example to ensure a positive culture had been created, placing people's needs and a sense of community at the heart of the service. We saw that people and staff were happy in their roles and there was a warm, friendly and relaxed environment.

Improvements in the service had been established, embedded, and sustained. Staff at all levels understood the shared vision of being transparent and proactive, to support people to achieve their goals and keep them safe from avoidable harm. The staff and management were all looking at ways to continue to learn and improve and ensure that lessons learnt were embedded into practice.

Staff told us leaders were visible. The registered manager ensured there was an open-door policy, and this was seen on the day of our visit. The registered manager regularly worked alongside care staff to understand concerns raised and mentor new staff to help them familiarise themselves with the organisation. The manager told us they were fully supported by the provider and had had a good induction.

Staff knew how to raise concerns and access support. There were clear procedures for regular team meetings. Staff consistently told us the registered manager worked alongside them to continuously make improvements. Processes were in place in the service and this meant staff felt inspired to discuss their views and ideas. Several staff told us, “The manager’s door is always open”, “I can go to the manager anytime” and “The open door policy is appreciated by all staff.”

Staff felt they could speak up and report issues and concerns to the manager. They told us they would be listened to, and action would be taken. Staff and management ensured they were open and transparent. Any issues or concerns raised were dealt with and learnt from.

The provider had invested in opportunities for staff to feel valued and supported in the workplace and provided them with tools recognise abuse and be confident to Speak Up. We reviewed the complaints log and found they were all investigated and closed. The service had also received compliments from families, relatives and friends.

The service had effective and proactive ways to engage with and involve staff. Staff told us they felt heard, and this enabled them to achieve good outcomes for people. One staff member commented, “I feel supported in my job role. I am always listened to, we all communicate really well and always get positive feedback for the jobs we do.”

Policies and procedures incorporated all aspects of recruitment and staffing and included retention plans, equality, diversity, fairness and protected characteristics. The provider was passionate and committed to having an inclusive workforce. Support and reasonable adjustments were made for staff as and when needed.

Staff gave consistently positive feedback about working at the service. They told us they felt supported and listened to by the management team. The registered manager was approachable, open, and there was good communication at all levels. Some staff members undertook champion roles in preventing the control of infection, pressure care and end of life care. They sought good practice, and this was cascaded through the staff teams. A staff member told us, “I am one of the infection control champions here, I have been in this role for 3 years plus. I complete with all staff competencies on infection prevention and control, making sure they understand everything and meeting the criteria in full.”

Although systems were in place, these were not always effective and did not always evidence oversight to fully manage the quality of care and service provided. Audits were undertaken and issues were identified, however appropriate action was not always taken. We did see an action plan implemented, and checks were carried out to ensure completion of most actions, however not all. Any learning identified was discussed with appropriate people, for example, staff/residents/relatives through communication channels such as handovers, meetings, and reviews. We also saw quality and clinical governance meetings and clinical matters were discussed and reviewed, and lessons learned considered.

People attended residents’ meetings which enabled people to have the opportunity to have their say on the service provided at Aberford Hall. One person told us, “We have residents’ meetings and I feel listened to.” A relative commented they had observed changes following a suggestion they had made.

The manager worked very proactively in creating partnerships with health and social care professionals, and organisations providing people with access to community services.

Health and social care professionals told us they worked together with the staff and manager as partners.

Systems and processes were in place to ensure the service worked with partners and the local community.

The registered manager told us about the ways in which they were continually looking to improve the service. This included listening to feedback and being proactive in identifying learning opportunities through their audits. The manager had an understanding of how to make improvements happen. Their approach was consistent, collaborative and inclusive. There were processes to ensure that learning happened when things went wrong. The provider encouraged reflection and collective problem-solving.

Governance systems and processes were in place to monitor the overall safety and quality of the service. Regular audits were undertaken across the service and any trends in people’s care, accidents or incidents were analysed and appropriate action was mostly taken. We noted that some record keeping needed improvement. This would ensure that the registered manager had better oversight to ensure people had their needs met. The registered manager had implemented new processes because of lessons learnt from accident, incidents, complaints and concerns. Notifications were consistently submitted to external organisations as required.