Aldercar Residential 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. At our last assessment we rated this key question good. 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 service was in breach of legal regulation in relation to governance at the service.

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.

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.

The provider had experienced a period of management changes, which had impacted the culture within the service. At the time of inspection, a new management team was in place and working to embed a positive culture and establish a shared vision and direction for the service. However, due to gaps in record-keeping and documentation, the provider did not always have access to accurate and up-to-date information to fully understand and respond to the needs of people using the service.

The provider had not ensured the recruitment of competent and capable leaders, which had impacted the staff team, the quality of care provided to people, and the effectiveness of governance arrangements. Staff spoke negatively about their experiences under previous management. However, both staff and people expressed more positive views about the new management team, who demonstrated a commitment to driving improvements and embedding positive change within the service.

The provider had a whistleblowing policy in place; however, this had not been effectively embedded in practice. Staff told us that under previous management they did not feel confident or supported to raise concerns and described the culture as closed rather than open. This indicated the provider had not established an environment where staff and people felt able to speak up freely.

Since the recent changes in management, improvements were evident. The new management team had taken a more transparent and inclusive approach and were actively working to promote a positive ‘speaking up’ culture. Staff told us they felt more confident that concerns would be listened to and acted upon, which demonstrated progress towards creating an open and supportive culture within the service.

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.

Staff described feeling disempowered, fearful and demoralised under previous management, and told us they did not feel supported or valued in their roles. However, since the introduction of the new management team, staff reported improvements in morale and engagement. Staff told us they felt more involved in the service and that their contributions were recognised and valued, indicating a positive shift in the culture.

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.

The provider had lost oversight of the service and there were ineffective auditing systems in place, which had not identified the significant shortfalls outlined throughout this report. Under previous management, roles and responsibilities had become unclear, leaving staff uncertain about their duties. At the time of inspection, the new management team was in the process of clarifying roles and establishing clear lines of accountability for the staff team.

We also found that confidential information was not always stored securely. For example, the staff room, where records were kept, was left unmonitored and accessible throughout the inspection, which increased the risk of unauthorised access to sensitive information.

The provider was not meeting their statutory and regulatory requirements under the Health and Social Care Act 2008, the Care Quality Commission (Registration) Regulations 2009, or the Mental Capacity Act 2005.

These were significant shortfalls and we have asked the provider to take action, which they have started to immediately.

The provider did not consistently demonstrate an understanding of their responsibility to work collaboratively with others to ensure joined-up, person-centred care. Information and learning were not always effectively shared with partner agencies, and opportunities to work jointly to drive improvement were missed.

Although feedback from external healthcare professionals was generally positive, the service had not always recognised when people’s health needs had changed or deteriorated. Referrals to relevant professionals were not always made in a timely way to ensure people received appropriate support. For example, when one person was observed to be coughing during a meal, this had not been escalated to their GP for further assessment, which placed the person at potential risk.

The provider did not consistently share important information with external agencies, including making safeguarding referrals when required. In addition, the provider had not always acted promptly on concerns identified through audits undertaken by partner organisations, such as the local authority.

These were significant shortfalls and we have asked the provider to take action, which they have started to immediately.

The new management team described to us their plans to be more inclusive with the local community, including inviting local groups into the home and support people to attend the local church.

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 and research.

There were no effective systems in place to enable the service to learn from incidents, accidents, near misses or safeguarding concerns. As a result, opportunities to identify trends, mitigate risks and drive improvement were missed.

Where concerns had been identified through both internal and external audits, appropriate and timely action had not always been taken. This meant improvements were not embedded in practice, placing people at risk of receiving care that did not consistently meet expected standards.