Alma Barn Lodge

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

We looked at 3 quality statements under the Well Led key question: Workforce equality, diversity and inclusion, Governance, management and sustainability and Learning, improvement and innovation. During our assessment of this key question, we found there were continued shortfalls in the way the service was led. This meant some regulations were still not met and provider remained in breach of regulations. The delivery of high-quality care was therefore not assured by the leadership, governance or culture in place. We identified ineffective systems and processes in place to assess, monitor and improve the quality and safety of the service. Systems and processes to ensure records were accurate, complete, and kept up to date were not effective. This resulted in a continued breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 50 (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.

There were processes to review and improve the culture of the organisation in the context of equality, diversity and inclusion. The provider had reviewed any disparities in the experience of staff with protected equality characteristics, or those from excluded and marginalised groups and took action to make improvements when necessary.

Staff did not always feel listened to. Staff told us due to changes in management and the differences in each managers style, the culture of the service changed with each new manager. However, one staff member said, "We have improved since last time, in the right direction but still not perfect."

Systems and processes were not always effective in assessing, monitoring and improving the service. Reviews and audits of people’s care files and risk assessments had not always identified when information was missing or inconsistent. For example, monitoring and actions in relation to diabetes care. Systems and processes had failed to identify and mitigate risks when insufficient levels of trained staff were deployed. This put people at risk of not having their needs met. Systems and processes to audit and review daily tasks records or mitigating strategies were not effective. For example, support with repositioning records, fluid records, and pressure mattress setting checks.

The manager understood their roles and was aware of their duty of candour responsibility. Staff knew how to whistle-blow and knew how to raise concerns with the local authority and the Care Quality Commission (CQC) if they felt they were not being listened to or their concerns were not acted upon. When needed, the management team provided information to help with any enquiries into matters.

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.

Systems and processes were not effective in ensuring improvements were made to service in a timely manner. At the previous inspection we found breaches in regulation and issued an enforcement notice, this gave the provider a clear timeframe to address these concerns. However, we continued to find similar concerns on this inspection. This evidenced learning and improvement required significant improvement. The provider had not demonstrated an understanding of ensuring the principles of good quality assurance were effective to drive improvement.

Learning from incidents had not always been effective. During the inspection we found concerns with the management and recording of diabetic information. These concerns had not been identified prior to our feedback. Therefore, an investigation had not been completed and lessons learnt. Staff felt improvements had been made since the previous inspection. However, they also identified there were still concerns that had not been rectified.