Alistre Lodge Nursing & Care 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. We identified 2 areas which breached the legal regulations. The manager had been in post for 5 weeks and was awaiting to be registered with CQC. At the time of our assessment recruitment, support and development of the manager was not sufficient to ensure they had the skills, knowledge and credibility to lead effectively. We observed concerns around data protection; and governance systems were not used to adequately record, monitor and improve standards. However, morale at the service was generally good. Staff spoke about the manager positively, and felt they were treated fairly and had the freedom to speak up.

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.

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

Leaders were visible and lead by example, this was confirmed in the most recent staff survey. The manager spoke about their nursing and clinical background and advised they would be undertaking further qualifications to improve their knowledge and capability in the role. However, they told us their own medicines competence had not been checked in line with best practice guidance. This meant we were not assured they had the knowledge, understanding and skills to administer medication and assess other staff.

We could not be assured leaders were knowledgeable about issues and priorities of the service. The manager spoke of meeting between themselves and the nominated individual, but these had not been documented meaning there was no evidence of actions taken or agreed improvements. Recruitment of the manager was not safe, they had potential gaps in their employment history which had not been explored and their application form had not been fully completed. The manager had not received the appropriate support or development in their role; they had not received an induction when commencing employment or had regular competency checks.

Staff confirmed they were encouraged to raise concerns and felt confident their voices would be heard, but meetings were infrequent. A staff member said, “I have raised small concerns with [the manager], and they spoke to staff to resolve things.” The manager confirmed they promoted a culture of speaking up; staff had recently been reminded of the provider’s whistleblowing policy during a team meeting.

A whistleblowing policy was available to staff and staff were prompted to raise any concerns in team meetings. Staff were also given the opportunity to share their opinions in a recent staff survey, anonymously if they chose.

The provider made reasonable adjustments to support staff. Staff gave examples of colleagues being given extra support during times of ill health or family crises. Staff told us they were treated fairly, and morale was improving. A staff member said, “I do think it’s a good place to work.”

The provider had a flexible working policy to ensure staff’s employment rights were taken into account; and the staff handbook covered topics such as working hours, sickness, dignity at work and pay.

The manager spoke about different governance systems used at the service such as clinical, care and kitchen audits. However, they acknowledged checks were inconsistent and there were currently no action plans in place to help monitor and improve the quality of care. Staff understood their roles and responsibilities, and those of managers and the auxiliary team.

Governance systems were not effective in ensuring a high quality service. Whilst audits and checks were in place, these were not embedded, and processes were not consistently completed. Issues identified during the assessment had either not been identified prior, or had been identified but not fully addressed Arrangements for the integrity and confidentiality of data and records was not robust. During assessment, we observed personal information such as medication administration records and care plans left in communal areas; in view of people living at the home, relatives and visitors. Data or notifications were not always submitted to external organisations as required. Please see ‘Safeguarding’ section of this report for more details. The manager told us confidentiality had been addressed in a staff meeting and advised of planned improvements for governance and oversight.

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.

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