Alexandra House

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. This is the first assessment for the service under this provider. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care. The service was in breach of legal regulation in relation to governance of the service.

This service scored 36 (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 there was an open and transparent culture at Alexandra House, they told us the registered manager was approachable. However, we found staff did not always promote an equitable culture in line with the providers values. The provider had visions and values in place which centred around safety, responsibility, care, bravery and individuality. However, staff did not always display theses visions and values to ensure all people received safe and effective care. For example, we found staff to sit and talk for long periods with the same small group of people at multiple times throughout our assessment. We found others were ignored and sat alone for long periods of time. We observed one person to eat their lunch alone without any support being offered despite them appearing to have difficulties holding their cutlery. We observed another staff member to make an inappropriate comment to a person living with dementia when they asked for food. This was not in line with the providers own processes and did not promote a culture based on equity, equality and human rights, diversity and inclusion.

The registered manager was experienced and supported by a deputy manager and operations manager. The management team recognised the environment needed work to improve people’s experience. Whilst the management team were experienced, they did not always identify when immediate actions were needed to keep people safe from harm. We found whilst audits had been completed, they failed to identify many areas for improvement. For example, we found broken lights and cracked plugs in people’s bedrooms. We found a recent audit had been completed and stated furniture and the building were in a good state of repair which was not an accurate reflection of the service. This meant that whilst processes were in place they were not effective in driving service improvement.

Staff told us the registered manager was approachable and there was a no blame culture at Alexandra House. Staff said if they had concerns, they would raise these with the registered manager. However, no staff spoke out about the incidents we observed during our assessment which raised concerns about the culture of the service. We found multiple areas of concerns, including safeguarding concerns and people being ignored, yet no staff raised this. This indicates staff were not confident in speaking out or did not know how to. There was a whistleblowing policy available to staff.

Processes in place meant not all staff were provided with equal opportunities to engage with their line manager during supervisions. We found some staff had two supervisions a year and no yearly appraisal whereas others had five supervisions and a yearly appraisal. This meant there was a risk that not all staff had their voice heard equally. The management team and staff had completed Equality, diversity, and inclusion training.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. Systems to audit the quality and safety of the service were not effective in identifying and addressing areas for improvement. Environmental audits were not effective in driving service improvement. Although environmental audits had been completed, these were not accurate and did not reflect the service. None of the environmental audits had identified uncovered hot radiators and exposed pipe work as being a risk to people. Infection control audits were ineffective and whilst some issues had been identified such as bedrooms being unclean. Other issues had not been identified, the home and equipment in it was visibly dirty. Records of care and support were not consistently monitored to ensure staff supported people in line with their assessed needs. We found multiple gaps in repositioning records which had not been identified prior to our assessment. The provider failed to act on known risks. For example, a legionella risk assessment had been completed in August 2024 with 10 actions needing completion. However, at the time of our assessment no action had been taken. This placed people at an increased risk of harm. The provider was reactive to our feedback and acted following our assessment.

The service did not always understand their duty to collaborate and work in partnership with others. People told us they were not involved in reviewing their care needs. A person we spoke with said, “They don’t involve me in reviewing my care not unless I ask them.” Another person told us, whilst staff supported them to see a doctor, they would like more privacy as they were often seen in the lounge with many other people present. People were supported to integrate with the local community to improve their experience. Staff told us they shared a minibus with other services and went out to garden centres. They also told us children from a local school visit. Staff said this had a positive impact on people, which they felt improved their overall wellbeing.

The provider did not focus on continuous learning, innovation and improvement across the organisation. We found there was not an effective system in place to drive service improvement. Audits in place did not always identify issues particularly issues relating to the environment. We found where incidents occurred improvements were not made to improve the safety and quality of care. For example, we reviewed a serious incident and a root cause analysis of the incident. The incident involved a person living with significant pressure damage. The analysis of the incident indicated that monitoring of pressure area care would be closely monitored and improved. However, we found this action had not been completed for the monitoring of pressure area care and that pressure area care remained poor. This was a missed opportunity to improve the safety and quality of care.