Alexandra Lodge 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

The provider had not implemented clear and effective governance, management, and accountability arrangements. Providers use these systems to manage and deliver good quality, sustainable, treatment and support. Staff were not always clear about their responsibilities as part of their role which meant tasks were sometimes missed. There was a current safeguarding and whistleblowing policy in place. Although not all staff were clear about the procedure for externally reporting concerns, all staff felt able to speak up about concerns and approach the registered manager. Implementing more robust governance processes would support the provider to have increased oversight of the running of the service, identify issues earlier to improve the quality of care and treatment, and provide opportunities for learning. Failure to learn from when things go wrong means there is the potential for the same issues to reoccur.

This service scored 29 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a policy in place for Whistleblowing, this provided staff with information to support them to make a disclosure should they have any concerns regarding the home, staff or management including concerns regarding abuse of people using the service. The providers' policy encouraged staff to speak up about concerns, external agencies to report concerns to and signposted staff to the safeguarding policy. The provider had not implemented a process to demonstrate that staff had read and understood the policy to provide assurance that staff were familiar with them.

We spoke with a staff about speaking up if they had any concerns and the whistleblowing policy. Staff were able to tell us where the policy was located however, they were not always clear about the process for reporting concerns. They told us, “We have been learning about whistleblowing and what to do.”

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 provider had not implemented clear responsibilities, roles, systems of accountability and good governance. Providers use these systems to manage and deliver good quality, sustainable, treatment and support. The provider had put limited processes in place to support good governance and some processes previously absent had recently been implemented. This included medicines stock checks and some infection prevention and control auditing processes. Implementing more robust governance processes would support the provider to have increased oversight of the running of the service and identify issues earlier to improve the quality of care and treatment.

The registered manager told us that some processes had been implemented to improve management oversight which included completing audits. They advised the inspection team that they had arranged for an internal assessor to come to the home to carry out a risk assessment, as the one currently in place hadn’t identified areas of risk, who was attending in May.

We spoke with the registered manager about learning and improvement who told us, “I am teaching all staff, things like emergencies and there is on call for support. I want everyone to be responsible for everything. We are very proud; everything is documented, and we encourage each other."

The provider did not have robust processes in place to support learning and improvement. There was no evidence of how the registered manager was teaching staff as described. There was no analysis of identified issues to support learning from when things go wrong, or that this was shared with the wider staff team. Failure to learn from when things go wrong means there is the potential for the same issues to reoccur.