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

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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

There was no registered manager at the service. The previous management had not instilled a culture of care and good teamwork, and provider governance systems had failed to recognise and address this. With input from a temporary management team and local authorities, the service had been supported to keep people safe until they had transitioned to other providers.

The provider failed to ensure systems to assess, monitor and improve the quality and safety of the service were in place and effective. We found ineffective audit systems in place related to: Staffing, Safeguarding, Health monitoring, safe environments, and care records. We also found monitoring and oversight of ensuring people care and support was person centered and reflected best practice was limited. There was limited evidence since our last inspection of the service of how the provider had worked with people to enable them to enjoy a full life.



In relation to staffing the provider had failed to identify significant risks in a timely way in relation to staff recruitment, and incorrect training and monitoring records.

The provider had failed to identify gaps in training and incorrect training records. There is no system in place to effectively monitor the understanding and effectiveness of training.

There is no monitoring in place to identify gaps in reporting and data analysis in relation to safeguarding people from harm and abuse.

There were inadequate care records to monitor and identify health problems such as constipation management and there were no early warning systems in place to identify emerging health risks

The manager reportedly carried out twice daily walk arounds but had failed to notice a boiler cupboard which was unlocked. We had to ask them 3 times to resolve this.

There were anomalies in care records related to diagnoses which had not been identified and rectified by the provider’s audits and monitoring.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We spoke to staff and read staff meeting minutes. Staff expressed concerns about direction and advise they had been given. They said that “on separate occasions the team had been given different instructions by the Manager”.

We saw no evidence that staff and leaders had developed a structured planning process of visions, values, and strategy in collaboration with people who use the service, their advocates, or external partners. There was no clear vision for staff to understand how their role helped it to be achieved.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We saw policies were in place to support staff with whistleblowing and speaking up. Staff told us that they had not felt that their concerns were listened to. In meeting minutes, it was recorded “A team member complained that when issues/complaints are raised that nothing is usually done by the management hence the reluctance to voice out and attend meetings”. We saw evidence of the current leadership team speaking up to the provider about unsafe recruitment processes.

Staff spoke positively about the current management team. One staff member told us they felt they “would be listened to if they had any concerns”. We saw that freedom to speak up was discussed at team meetings.

We saw policies in place and induction records to evidence staff are made aware of it. However, staff meeting minutes did not support that staff had felt able to this. We saw some improvements in later minutes that staff were being encouraged to feel able to speak up if needed, and that staff had done so via whistleblowing systems.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff told us that the previous leadership impacted on their morale, and that the leadership team did not have a clear understanding of their personal circumstances which impacted on their role. We saw team meeting minutes where staff vocalised their confusion and concerns about managing peoples care safely.

The provider failed to ensure there were robust audit and governance arrangements in place to proactively, effectively monitor and identify short falls in the service. This includes identifying where improvements to quality and safety could be made to minimise risks for service users, staff and others. Improvements were needed to the quality and experience for people using the service. There was minimal evidence of learning from incidents, reflective practice or service improvement, as a result people continued to be at potential risk of harm.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.