Archived: Alderwood L.L.A. Limited - Hayway

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• 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.

At our last assessment we rated this key question outstanding. At this assessment, the rating has changed to 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 71 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider shared their direction in their Impact Report for 2024-2025. This included information about safety cultures, their drive to continue and develop co-production, as well as how they plan to keep people at the centre of what they do.

On a service level, there were concerns previously of a closed culture, however since the new management team had come into post, we saw evidence of them taking strides to eradicate any closed culture and ensure there was a culture of openness and transparency. The manager spent time explaining and promoting this culture and way of working with staff, for example, in team meetings.

The provider had a published set of values, which were ‘being brave, having fun, making things happen and valuing everyone.’ We found that the service embedded these values in their day-to-day work.

Leaders and managers had developed an individualised objective plan for 2025 for the service, this included embedding more active support to support people to reach goals and developing the environment to be more person centred by introducing things such as sensory rooms.

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.

During some of our observations on site that were concerning, senior members of staff were present and involved. We were not assured of their ability to lead, as they had not challenged practices. This was shared with managers and leaders, who were already working to develop and coach senior members of staff, and augment their understanding of their role and responsibility.

The provider fostered a positive culture where people felt they could speak up, and their voice would be heard.

We found that managers regularly promoted the freedom to speak up movement, during staff team meetings, via posters displayed around the service and being approachable for staff to share concerns.

The provider had an app, which enabled people to raise concerns anonymously to anyone within the organisation.

Staff had good knowledge of how to raise concerns internally and externally, if they felt their direct line managers were not taking them seriously or taking action.

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 provider made sure that staff felt respected and valued. Staff told us leaders made them feel valued and felt supported. However, one staff member felt their personal circumstances were not accommodated when it came to shift patterns, although they were generally happy within their role and working for the provider. We found that the provider did consider reasonable adjustment requests, however, if they were not able to meet people’s needs by facilitating these, they were unable to agree them.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these 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.

At the time of our assessment, we were assured by the systems in place which gave managers and leaders oversight of the service. However, we were not assured that these systems had always been effectively utilised, as issues found by leaders following two whistleblowing events, had not been found or rectified prior to this.

There was multi layered audit system in place that saw staff completing regular checks and documentation, for the manager to review during audits. The managers audits would then be ‘spot checked’ by leaders within the provider. At the time of our assessment, this was being effectively completed, and we found managers and leaders had good knowledge of what was happening within the service on a day-to-day basis.

There was a good level of emergency preparedness, and guidance was available for staff should emergency situations arise.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff and leaders worked proactively with local partners and community organisations to enhance the lives of people. Additionally, they maintained strong links with healthcare professionals, social workers and other external professionals to ensure individuals received coordinated and holistic support.

People were encouraged and supported to access community resources such as leisure activities and volunteering opportunities, promoting inclusion and independence. The provider collaborated with families and external agencies to share best practice and improve outcomes.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

Staff and leaders understood how to make improvement happen, and each were dedicated to their roles within this. For example, staff would document achievements, or things that didn’t work well, so others could learn from their experiences. This information then fed into learning at service level to develop the provider’s approach.

We found during our assessment that leaders welcomed feedback and guidance where it was given and were prompt to take action to improve the service for people.

The provider shared concerns, incidents and events with external organisations and worked alongside them where necessary to improve and learn.

There was a collaborative approach to learning. People, relatives, staff, managers and leaders were involved in collective problem solving where appropriate, which was one of the way staff told us they felt valued by the provider.