Aldergrove Manor Nursing 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

The service was not consistently well led and remains requires improvement. Not enough improvements had been made and we identified a continued breach of the legal regulations. The governance and oversight systems had not ensured there were sufficient staff or that risks to people’s safety were fully assessed. There were concerns identified through the governance systems with medicines guidance, but the system had not ensured these were acted upon. The system to action repairs had not been effective in ensuring actions were taken.

This service scored 54 (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.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager told us they had support from a management team including support to deputise for them and support from an area-based team. The registered manager was clear about their role and could describe the systems in place to support them with checking on the quality of the care people received. For example, they could describe in detail how incidents and accidents were reviewed to draw on learning and how checks were carried out on people's care documentation such as fluid charts. The registered manager told us they had made changes since the last inspection, for example they had changed the checks done on people's fluid intake to ensure prompt action was taken when required. Staff told us they felt supported by the registered manager and things had improved since the last inspection.

There was no effective oversight system in place to ensure the required risk assessments and management plans were put in place when people were admitted to the service. Where audits were in place for areas such as medicines, they had identified concerns, but action had not always been taken to make the required improvements. For example, medicines audits had identified areas for improvements, and these had not been made. Systems were in place to report repairs required however these were not being used by staff and issues with the building and equipment had gone unreported, leaving people at risk of harm. However other quality assurance processes in place were working to drive improvements. For example, monitoring for fluid intake, catheter care and mattresses were all working to drive improvements.

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.