Archived: Priory Alliance Care Limited

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

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 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 service was in breach of legal regulations in relation to the governance of the service and fit and proper persons.

This service scored 29 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

There was no coherent direction for the service, and staff relied almost entirely on informal instruction rather than clear guidance or values. The registered manager and nominated individual did not ensure the service was operating transparently or in line with regulatory responsibilities. For example, they failed to notify CQC of changes to the location address or operating arrangements until repeatedly prompted during the assessment.

Care plans were generic, lacked identity, and did not reflect people’s needs, preferences or risks. Care plans contained identical eligible needs with only names changed, indicating leaders had not established a shared, person‑centred direction for the service.

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, and they did not do so with integrity, openness and honesty.

Leadership arrangements were ineffective and did not ensure safe or lawful care. The registered manager had limited understanding of regulatory requirements, including notification duties, recruitment rules, consent, mental capacity and care planning.

The provider was not involved in the assessment and provided no oversight.

Leaders did not demonstrate capability in core responsibilities such as ensuring staff competence, maintaining accurate records, carrying out supervision, or addressing serious risks such as unsafe medicines practice and unmanaged skin integrity risks. Managers also failed to recognise indicators of harm and safeguarding needs, despite clear warning signs.

The provider did not always promote a culture in which people felt safe to speak up or raise concerns. Staff told us they felt able to approach the registered manager if they had worries. However, we did not find evidence this was supported by an open culture, clear processes, or a transparent approach to learning from concerns.

The lack of openness and transparency within the service contributed to wider concerns about governance and staff practice. For example, inspection findings showed that important information was not shared with the local authority and there were inconsistencies between what leaders reported and what was found during the inspection. These issues indicated an absence of a learning culture and did not support an environment where staff could speak up.

There was no evidence the provider had effective systems for monitoring, responding to, or learning from concerns raised by staff, people or relatives. Spot checks were informal, lacked detail, and were not signed by staff to confirm what had been reviewed. This meant there were limited mechanisms for staff to raise issues safely or for leaders to identify themes, trends or early warning signs.

Although some staff told us they felt able to speak up, the provider did not have effective systems to support this, nor did we find evidence of an open and transparent culture in practice. This meant people and staff were at risk of concerns not being identified or acted on appropriately.

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

The provider did not promote an inclusive or equitable working environment. Staff files lacked essential information, including employment history and reference verification which disproportionately affected staff confidence and fairness of recruitment.

Training was applied uniformly but without consideration of individual learning needs or prior experience. Staff with no care background were expected to meet the same competencies without support, resulting in unsafe practice.

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 was wholly ineffective and did not ensure safe, lawful or sustainable care. The registered manager did not understand or comply with their regulatory duties. Notifications were not submitted as required, the registered location address was incorrect, and the service was operating from an unregistered premises. These failures demonstrate a lack of understanding and oversight of legal responsibilities. They also represent clear breaches of the Care Quality Commission (Registration) Regulations 2009, which require providers to notify the Commission of specific events, maintain accurate registration details, and operate only from locations that are properly registered.

There were no audits of care plans, medicines, risk assessments, call times, safeguarding, training, recruitment or incidents. The only audit undertaken was a daily notes check, which failed to identify repeated omissions, inaccurate records, duplicate entries or lack of care detail.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.There was no evidence of routine engagement with healthcare professionals such as district nurses, GPs or occupational therapists. Information shared by the provider with partner agencies was inconsistent or inaccurate, including contract start dates and assessment details.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice.

Training records showed identical completion dates across all modules for multiple staff, suggesting the provider did not assess competence or learning needs. There was no system to evaluate whether training was effective or integrated into practice. Staff demonstrated significant knowledge gaps, including an inability to explain diabetes risks, mental capacity, medicines safety or escalation processes.