Archived: DCA Alderwood North

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 this newly registered service. This key question has been rated requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service. 

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.

The provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. There was an inconsistency in the leadership and culture of the service. There was a disconnect between the management team and the staff team. One member of staff told us, “I have been employed for just under 1 year. The amount of staff I have seen leave or come and go and the amount of management that have left is high. It’s run, it is not organised. How can you work in a place that has very little training. They keep saying changes are coming changes need to be made I have not seen any. When I have tried talking to management about my concerns or issues all I get told it’s your job you deal with it, maybe this is not the place for you, maybe you should look elsewhere.”

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively. We saw limited evidence the management team were compassionate and inclusive leaders. There was a clear disconnect between the management team and the staff team as a result of ineffective leadership and management. Staff feedback about the management was not wholly positive. A member of staff told us, “There has been no supervision for my care, there has been a probation meeting but I do not know what it was based on. There have been no supervision sessions where a manager has been observing me caring for a person we support.” Another member of staff told us, “The organisation and management do not respond to needs or concerns I raise and tend to move me onto a different service user rather than take feedback seriously. None of [the staff team] are monitored by managers, I don’t know what monitoring the management have [in place].”

Members of staff felt they could speak up; however, they felt their voice was not always heard. There was a policy in place to support staff to speak up and staff confirmed they had spoken up and raised concerns both inside of and outside of the provider organisation. A member of staff told us, “The whistleblowing process the provider has is flawed, as I had to discuss my concerns with [a member of the senior management team] who was aware of the situation but defended the manager’s actions.”

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. The management team told us they supported diversity in the workplace and members of staff did not raise any concerns about diversity in the workplace. We observed there was a diverse workforce and people work together in diverse teams and groups.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Governance systems and processes were not effective in identifying key areas for service improvement and development. Audits and reviews had not identified deficiencies in people’s care plans and risk assessments. For example, people’s risk management plans did not include a review of all risks to individuals and there was limited evidence people’s behaviour support plans had been regularly updated and reviewed. A recent quality audit carried out by the provider had highlighted areas for improvement but there was no evidence to indicate whether developments and improvements had been made and reviewed to provide assurance changes had been embedded into practice. There was poor leadership and governance of the service which was a risk to people and resulted in care which was not always safe.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. We saw evidence the provider worked with local health and social care partners. People accessed the local community and enjoyed visiting local amenities.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. Lessons learned from other services in the wider provider group and network were not shared or implemented within this service and there was limited evidence of a culture of continuous improvement and development.