Alderbrook Care Home

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 good governance.

This service scored 46 (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.

Although the provider and senior leadership team expressed a commitment to delivering high ‑quality care, and staff understood the importance of doing so, this had not been effectively implemented or embedded within the culture of the home. Inconsistencies within the management team meant that the service’s vision and values had not been clearly communicated or discussed with staff, resulting in a lack of shared direction.

Not all leaders understood the context in which the provider delivered care, treatment, and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience, and credibility to lead effectively, or they did not always do so with integrity, openness, and honesty.

The provider and management team had identified areas requiring improvement within the service and had begun work to address these. However, during this period of change, staff reported feeling unsupported and described a culture of blame rather than one that promoted learning, development, and continuous improvement.

The service had experienced significant instability in leadership, with two interim managers in post over a short period. The registered manager position remained vacant and had not yet been recruited to, resulting in a lack of consistent leadership for staff. Although the interim managers had begun to review and develop systems to support improvement, these had not been implemented or embedded. This lack of stable leadership had a negative impact on staff, who told us they felt they did not have clear direction or support.

People did not always feel they could speak up and that their voice would be heard.

Although a whistleblowing policy was in place and staff were aware of it, some staff reported that they did not always feel able to raise concerns without fear of negative consequences. They were not consistently confident that any concerns they raised would be addressed appropriately. One staff member told us, “I have raised my concerns regarding staffing levels and working across services; however, this was dismissed by management.”

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

We saw little evidence that the management team supported flexible working arrangements when staff required adjustments due to personal commitments or caring responsibilities. Staff told us they did not always feel they were treated fairly. One staff member told us that whilst they were off work unwell, they received a notification informing them they were due on shift, this caused undue stress to the staff member at a time when they were already unwell.

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.

Although audits had been completed, the gaps identified by the recent interim manager had not been appropriately addressed. Infection prevention and control audits, as well as environmental checks, had highlighted concerns such as meals being taken to people’s rooms without covers; however, this practice was still occurring on our second visit. Audits had also raised issues regarding both the absence and the quality of staff supervisions and team meetings, along with concerns about how these were documented. Despite these findings, the actions required to resolve them had not been fully implemented, and many staff members had gone an extended period without receiving supervision.

Governance processes had not identified the lack of follow‑up actions from resident and staff survey responses. Audits of accidents and incidents had also not consistently recognised that learning from investigations was not being shared with staff when appropriate. While systemswere in place for recording and reviewing people’s care and support, the quality of these records did not always meet expected standards and was sometimes contradictory. This included inconsistencies in daily monitoring records and in documentation relating to mental capacity assessments and best interest decisions. Additionally, the electronic system being used did not enable staff or managers to easily access or analyse important information, limiting the provider’s ability to effectively monitor risks or ensure continuity of care. As the interim manager explained, “I can’t get into the system and drill down to gain the oversight I need.”

Following feedback from the inspection team, the management team confirmed that immediate action was being taken to address these issues.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

A lack of effective oversight and monitoring within the service reduced the provider’s ability to work collaboratively and to share information in a timely and meaningful manner with internal and external partners.

Following feedback from the inspection team, the management team confirmed that immediate action was being undertaken to address these issues.

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.

The management team acknowledged that their existing quality monitoring systems had not effectively supported reflective practice or driven continuous learning and improvement within the service. They provided assurance that newly introduced governance arrangements would include more robust auditing processes, with analysis used to inform learning and support ongoing improvement.