Alexandra Park

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 inspection we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

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

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Some staff told us that the culture at the service was not positive. Staff gave examples of poor direction from the management team, including, “I’m scared in case of a backlash to say anything” and “Can you take it off Lifeways and give it to someone who cares.”

Management staff told us that not all staff had accepted the changes they were making to ensure improvements were made, which had led to negative feedback being provided and anonymous concerns raised to CQC.

Improvements were required to ensure processes were in place to make sure people achieved positive outcomes and staff were enabled to contribute to the development of the service.

Some staff told us that concerns raised were not always acted upon and management staff were not always approachable or visible around the service.

Our findings at this assessment did not evidence that leaders had the capacity and capability to ensure high quality care was delivered and risks appropriately managed. We identified shortfalls in relation to medicines, the management of people’s monies, mental capacity, the assessment of people’s moods, meeting people’s social needs, staff training and support, environmental safety at night and nutrition and hydration which had not been identified or addressed by the management team.

There was no registered manager in place. The previous registered manager deregistered in March 2024. There had been several managers covering the service in 2024. Management staff told us a new manager had been appointed together with 2 deputy managers and team leaders to ensure there was effective oversight and management of the service.

Some staff told us that concerns raised were not always acted upon and management staff were not always approachable or visible around the service. A staff member said, “The management team need more support.”

We received feedback via our ‘Give feedback on care’ webform about bullying and racism, which it was alleged were not being dealt with by management. Management staff explained that negative feedback received was from those staff who had not accepted the changes they were making to ensure improvements were made.

An effective system was not in place to ensure staff were actively enabled and promoted to raise concerns and speak up. Whilst policies and procedures were in place to support staff to speak up, some staff told us management staff were not always receptive or available.

Records we reviewed such as handovers, management walkaround checks and accident and incident records, did not always evidence management oversight to demonstrate that management staff were aware of any workforce issues or concerns so timely action could be taken.

Some staff said they did not always feel valued and the culture which management staff created was not always positive. We also received feedback about bullying and racism.

Following our assessment the new manager contacted us and stated, “We are currently working on building relationships with the staff team and though there is still a lot of work to be done, I am confident that we will get Alexandra Park where it needs to be.”

Whilst systems were in place to try and promote equality, diversity and inclusion, most staff told us that the systems currently in place were not effective.

Records we reviewed such as handovers, management walkaround checks and accident and incident records, did not always evidence management oversight to demonstrate that management staff were aware of any workforce issues or concerns so timely action could be taken.

We received feedback from staff that management staff were not always supportive or visible around the service.

Management staff told us managers were always available. They felt the negative feedback received was from those staff who had not accepted the changes they were making to ensure improvements were made.

An effective quality monitoring system was not in place to ensure regulatory requirements were met. We identified shortfalls in relation to medicines management, the management of people’s monies, mental capacity, the assessment of people’s moods, meeting people’s social needs, staff training and support, environmental safety at night and nutrition and hydration. The provider's quality assurance processes had failed to identify these areas of concern or ensure that timely action was taken to address the issues.

A robust system was still not fully in place to ensure events at the service were notified to CQC in line with legal requirements. We had not been notified of the outcome of a DoLS application. This failure to notify CQC of reportable events at the service had been raised at our previous inspection.

This is the third consecutive inspection where the provider has been in breach of the regulation regarding the management of the service. We have taken this into account when scoring this quality statement.

Relatives raised concerns about communication systems. This posed a risk to partnership working and people’s wellbeing.

Several staff told us that management communication systems needed to improve to ensure there were effective communication channels in place to ensure people received joined up care.

We found examples where poor communication and lack of management oversight had affected partnership working.

Management staff told us a new manager had been appointed together with 2 deputy managers and team leaders to ensure there was effective oversight and management of the service.

Most health and social care professionals told us that communication with the service was poor. A healthcare professional said, “Things have been turbulent with Alexandra Park this year due to multiple changes to management. It has at times been difficult to get responses to correspondence in a timely manner.”

A representative from the local authority told us there had been a lack of evidence provided to demonstrate that the improvements required had been implemented. They stated however, “The local authority will continue to work to positively engage with the provider to ensure recommendations are agreed and implemented.”

An effective system was not in place to ensure the service worked effectively with health and social care professionals to ensure action was taken to improve.

The service was in organisational safeguarding measures at the time of this assessment. This meant the local authority was monitoring the service and supporting them to ensure the correct procedures were in place to keep people safe. Sufficient action had not been observed by the local authority to enable the service to be moved out of these measures.

Several staff told us improvements had not been made and there were still ongoing issues with the service and culture.

Management staff told us improvements had/were being made and negative feedback received from staff was from those who had not accepted the changes they were making to ensure improvements were made.

An effective system was not in place to identify and share lessons learned so action could be taken to minimise the risk of any reoccurrence.

Despite previous inspections highlighting shortfalls and concerns, we found these concerns remained. Systems in place to monitor the quality and safety of the service remained ineffective.

This was the 8th consecutive inspection since 2015 where the provider had failed to achieve an overall rating of at least good. We have taken this into account when scoring this quality statement.