Alderwood

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 the last inspection we rated this key question good. At this inspection the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. 

This service scored 86 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities. This was evident in the way staff consistently worked in line with the provider’s values of transparency, equity, and inclusion. The service’s culture was embedded through visible displays of CQC domains and regular discussions at team meetings, ensuring staff understood expectations and contributed to continuous improvement. Staff feedback confirmed they felt part of a positive culture where their views were listened to and acted upon. Relatives and professionals described staff as compassionate and committed to achieving good outcomes for people. Examples such as the “Proud Journey” booklet and themed activities demonstrated how the vision translated into practice, supporting people to regain independence and live well in the community.

The provider had exceptionally 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. They always did so with integrity, openness and honesty. The provider had recently won an inclusive culture award. The senior executive team, senior management team and trustees regularly visited the service to gain people’s views and suggestions for improvement. They were always working toward providing the best possible support for people experiencing mental health difficulties. We found their empathetic, caring and person-centred approach had filtered down and influenced the manner staff worked with people.

Leadership at Alderwood was visible, approachable, and highly regarded by staff. Feedback from staff highlighted that managers provided regular supervision, were responsive to concerns, and encouraged professional development through access to training and reflective practice. The management team demonstrated integrity and inclusivity, fostering a culture where staff felt valued and supported. Professionals noted the team’s ability to manage complex mental health needs effectively, while relatives praised the dedication and professionalism of staff. These actions showed leaders were capable and compassionate, creating an environment where both staff and people using the service could thrive.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The Trustees were active members of the team and took steps to ensure they clearly understood the services and the impact these had on people’s lives. The senior management team and management team wanted to operate a positive culture where people felt they could speak up and their voices will be heard. Also, an environment where staff felt able to raise any issues and be confident these would be addressed. They actively promoted Freedom to Speak Up guardians and champions and really valued all the feedback they received. The people’s team consistently promoted access to guardians and encouraged staff to raise any matters. Their work had led to more staff feeling able to raise issues with them and managers. Staff felt their views and suggestions were actively taken on board. A staff member said, “The management team listens well and is always willing to take into account recommendations that could improve the service. I made some recommendations and they responded admirably.”

The provider and management team valued diversity in their workforce and ensured they followed best practices guidance. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. The provider had completed the diversity in health and care partners programme, which had aided a better understanding of how to promote inclusion. The senior leadership team actively shared this learning with the service. Staff described a supportive environment where diversity was respected, and reasonable adjustments were made. Training opportunities were widely available, and initiatives such as a prayer room for staff and service users demonstrated an understanding of cultural and religious needs. The provider’s approach to fair pay and benefits, alongside efforts to maintain staff wellbeing, reinforced an inclusive culture.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. The Quality and Safety team had designed systems that readily assisted them and the staff to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. They constantly reviewed these systems and were continuously looking to see where enhancements could be made. Routine service reviews were completed, and these had been nuanced to suit each location.

Both senior managers and trustees took part in these reviews and completed listening exercises with people who used the service. These reviews produced meaningful improvements which were based on the views of people who used the service, their relatives and friends as well as staff. The provider ran regular meetings with people from the service and service user representatives attended the forums they ran plus the chief executive was available to call. The board and chief executive regularly visited the service and spent time with people gathering their views and ideas about the service and improvements that could be made.

The Quality and Safety team also produced deep dive tools and closely considered incidents and events to determine where lessons could be learnt. For example, the provider had completed a full analysis of the way staff managed medicine administration. Staff were clear about their roles and responsibilities, and there was evidence of systematic learning from incidents. Staff within the home also worked with universities and researchers to identify whether recent developments in practice within services for people with mental health needs were being effectively implemented at the service.

The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborate for improvement. People reported they found the staff closely tailored the work to individual’s needs and had supported them to experience positive outcomes. The service worked with external professionals, including GPs, community mental health teams, and Age Concern, to support people’s health and wellbeing. A professional said, “I have nothing but positive experiences with Alderwood. Their staff go over and above to work in a person-centred way. Always going the extra mile to support rehabilitation. They are skilled in working with clients who have complex mental health issues and contribute meaningfully to care and support planning to achieve good outcomes.”

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. There was a process in place for staff to ensure continuous improvement, through innovation and learning, was achieved. They had recently looked at CQC requirements, and the staff team had completed a comprehensive piece of work determining how the service met the single assessment framework. Staff found this exercise greatly benefited them, as they could see what was expected as best practice and how they could achieve this. Staff were actively encouraged to work with people in ways which aimed to improve outcomes for them and allow each individual to experience a good quality of life. The provider worked with local universities to research mental health difficulties and how support could be improved. The service also collaborated with universities and supported staff to engage in research and training, ensuring best practice was embedded. The registered manager ensured staff were supported to keep up to date with developments in best practice. Staff were encouraged to reflect on practice, and the nurses were supported to develop clinical reflective practice groups. A staff member said, “I feel a valued by the service and managers. Being supported by like-minded individuals whether organisational or within the team has let us look at the care and consistently make improvements.”