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Whetstone Grange

148 Enderby Road, Whetstone, Leicester, Leicestershire, LE8 6JJ (0116) 247 7007

Provided and run by:
A L A Care Limited

Report from 6 February 2024 assessment

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Well-led

Requires improvement

Updated 14 March 2024

We found the governance systems and processes were not always effective as they did not always identify shortfalls within the service. During our assessment of this key question, we found concerns around provider audits, oversight and leadership of the service which resulted in a breach of Regulation 17 Good governance (1) (2) (a) (b) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below.

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.

Shared direction and culture

Score: 2

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.

Capable, compassionate and inclusive leaders

Score: 2

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.

Freedom to speak up

Score: 2

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.

Workforce equality, diversity and inclusion

Score: 2

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.

Governance, management and sustainability

Score: 3

Staff understood their roles and responsibilities and were positive about leadership. The registered manager acknowledged there had been in delay in management audits and reviews for records such as care plans, risk assessments and environmental checks.

The internal audits, processes and procedures were not sufficiently robust and did not provide a comprehensive overview of risks within the service. There was no action plan in place to ensure improvements were made, embedded and sustained. Whilst the provider maintained contact with the registered manager, there was no formal oversight such as audits and checks completed on quality and safety.

Partnerships and communities

Score: 2

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.

Learning, improvement and innovation

Score: 2

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.