Adelfi Care Services

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.

At our last assessment we rated this key question Outstanding. At this assessment the rating has changed to Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The service was in breach of legal regulation in relation to failure to notify of safeguarding and serious injury events.

This service scored 75 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff and leaders demonstrated a positive, compassionate and inclusive culture that promoted trust and understanding between them and the people using the service. The provider sought to involve staff and people in shaping the direction of the service and keep them up to date with changes. A newsletter was shared within the service to update on people’s birthdays, celebrations, new staff starting, charity events of interest and useful and important information to aid people or keep them safe such as flu vaccination reminders.

There was a focus on extending support and contributing to a positive culture in the wider community in which people who were supported lived. The providers had locally donated money to support young players sports teams and clubs. One of the management team said, “We give back because we are a care company rooted in our community.” The provider had recently expanded the service into a new area. They had been careful to take a measured approach to this and create a new separate staff team and manager to oversee this so it did not negatively impact the current service being provided.

There was a sense of unity within the team with a shared goal of providing good care. We received comments about the service from staff such as, “Genuine care for staff and clients wellbeing alike. Good communication and forethought. Flexibility and can-do attitude. Great sense of local connection. Staff are very supportive” and “It’s an open door policy and I feel manager is approachable.”
 

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively.

There was a strong and capable leadership within the service that embedded positive values attitudes and behaviours throughout the staff team and care provided. This ensured that people were treated with respect and dignity and empowered to have choice and control in their daily lives.

People and their relatives praised the provider for their care, reliability and approachable nature. Comments included, “They are really approachable, flexible and I wouldn’t be worried about raising issues. They seem to be available all the time and get back to me straight away so I have no issues at all. I think they are really excellent and I would recommend them to anyone” and I think they are a very professional and caring organisation to deal with, I can’t think of an areas that needs improvement. I am very pleased we found them..”

The provider used their strengths, skills and experience to ensure that they led on different aspects of the service. This meant staff could utilise the support they needed from someone best placed to lead on that area. One staff said, “They are approachable and I would go to different people for different things.”

The leadership of the service ensured they undertook further training qualifications and kept informed of updates and research in the care field to ensure they remained knowledgeable and current in their practices. Staff told us, “Leadership is fantastic, they are always at the end of a phone or in the office if needed. As stated previously, someone is always on call and answer almost immediately.” and “I remember when I joined, I had a few questions, in previous jobs I’d be worried to ask as I felt judged. However, from the get-go I’ve found everyone really approachable. I remember saying to [registered manager], I’ve never felt so supported and I thanked her.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff were aware of whistleblowing procedures and knew how to share any concerns. Staff were confident that they could speak up and would be taken seriously by the management team. Staff told us, “Yes, I am aware. It means if I have any concerns or suggestions I am able to speak up without fear. I feel like I can speak up when needed, especially regarding client safety or well-being” and “It means that I or anyone else, have the right to speak up about things, and the right to be heard. I feel that I could raise any kind of issue, and it would be addressed in a respectful and appropriate way.”

We saw evidence of a transparent culture where people and their relatives were informed of events impacting their relative. The registered manager told us, “During medicines errors we made families aware and their right to complain, so didn’t hide this. We are an open book and legally we have to be but we are proactive in this, we have great relationships with most people and families. We just want the best for people.”

Staff received regular supervisions and we saw that these were another opportunity for staff to speak up about any concerns on an individual level. One staff member said, “Yes they are supportive, they allow any concerns or questions to be raised..”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us there was equal opportunities within the service and they had not experienced or witnessed any discrimination. Staff commented, “...They are clear and straightforward and genuinely value good relations. They have good ideas and offer constructive support and seem to respond very quickly. They are also open to ideas and suggestions from staff. Feels very healthy” and “...When I joined Adelfi, I instantly felt supported and heard which is really important to me.”

The provider was open in saying that the staff team did not appear particularly diverse as it was an all-female care team. They explained that whilst their employment criteria was open to all, most of their current support visits requested a female care member of staff so they had to meet this preference.

Staff spoke to us about ways in which the registered manager had provided reasonable adjustments to their ways of working. This included some staff working flexibly to suit around other responsibilities and commitments outside of work. The registered manager said, “Most staff work part time so all flexible, we have a fortnightly set rota and works around their life and if they want cover we do this.”

We saw that steps were taken to ensure staff were included as part of any decisions and changes impacting the service. The provider had recently expanded the service into a new area and this had been discussed at several meetings as the plans grew to ensure staff were kept informed. An employee handbook was given to staff when they started employment which included essential information about the service, their role and rights and useful external contacts for them such as the Local Authority, community nurses and non-emergency police.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We found that there had been an inconsistent approach in notifying CQC of any significant incidents. We found 3 safeguarding and 2 serious injury notifications ranging from 2024 to present day that had not been reported to CQC in line with the providers legal regulatory requirements. The provider told us this had been an administrative oversight, however there was a lack of understanding about when they should notify and the provider’s responsibility in submitting notifications. This had not been identified in any monthly audits. Due to this the service was in breach of the regulation relating to notifications of other incidents. Following our inspection the provider retrospectively submitted two of the notifications to CQC.

There were systems in place to regularly review the quality of service that people received. We saw that the audits looked at areas including medicines, care plans, visit data, feedback and accidents and incidents. An external audit process was also used which reviewed the governance of the service and produced a report of findings from which any actions could be taken. We spoke to the provider about reviewing their medicines audit process and notifications audit to ensure it remained robust in identifying any areas for action. Following this inspection the provider confirmed action had been taken to review and adapt these audits.

We saw that the last inspection rating report was displayed at the service and on the provider’s website in line with regulation requirements. A business continuity plan was in place which prioritised care needs in an emergency situation to ensure people who were most vulnerable received their support visits.

There was a good management structure in place at the service with clearly defined roles. Staff told us they felt the service was well led and organised with one staff member commenting, “It seems very well organised and well managed. We are able to operate individually and together, with clear guidance from Adelfi. The service is able to flex and change with demand, and this is managed in a clear and timely manner.”

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider told us they did not have much contact with external partners or the opportunity to work collaboratively. However, we saw that people’s care plans did evidence other professional involvement at times. This included occupational therapists and local authority and commissioning teams.

The registered manager was aware of resources available to them if they needed additional support for people, but seldom needed to reach out to implement this.

The provider was very involved in their local community and regularly took part in events and sponsored events that needed support. This included sponsoring local boys and girls football teams and rugby teams kits, charity events and amenities for a scout group. They spoke passionately about their service being part of the local community and creating these mutual partnerships to raise the profile of care and give back to good causes that needed funding.

The provider had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider worked hard to research and implement innovative practices that would benefit people, staff and the service as a whole. They told us, “We don’t want to be a normal care provider, we want to be one that cares. You can’t be the biggest and the best you have to pick and we chose to aim to be the best, and to do that you have to be different and we do things others don’t.” One staff member said, “We have the chance to share ideas and raise things in meetings including staff meetings, supervision meetings, or a staff survey is often carried out. Management are also really approachable so I always feel I can raise things rather than waiting for the chance to arise...”

There was a strong focus on using tools to improve people’s experience of care and their outcomes. For example, the provider had purchased a specialised emergency lifting chair to support people to stand following a non-injury fall. We saw that there was evidence recorded of staff using this chair to support people up and prevent them spending long amounts of time on the floor and at harm of developing further associated health risks.

The provider took the opportunity to learn from events and strive to find a better way and improve care for people. For example, following an incident where a person had to be admitted to hospital, the provider purchased specialised health monitoring equipment. This enabled staff to complete observations including blood pressure and pulse rate for people who consented, to create a picture of their normal baseline presentation to assist medical staff. This meant that unnecessary admissions to hospital could be prevented and also detect early signs of deterioration in a person’s condition. This proactive approach would have significant positive impacts for people using the service.

Preventing social isolation for people was a priority and the provider held a yearly social event to bring people together and for them to enjoy. The first had been held in January 2024 and was an afternoon tea with activities including flower arranging activity and pamper treatments. In January 2025 a seaside social took place with seaside live music, fish and chips, photo prompts and a punch and Judy show. The next event was planned for September and would be an indoor street party.