Archived: Alderwood LLA Ltd Addington Road

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 outstanding. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation 17 in relation to governance at the service.

This service scored 50 (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 have a clear vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. However, they did not always understand the challenges and the needs of people and their communities. The provider’s vision and values were known by the Registered manager and staff. However, they were not fully planned for or embedded into day to day practice. there was a lack of goal and aspiration planning or positive risk taking and support to enable people to try new things. Cultural changes were taking place at the service and the Registered Manager was embracing these changes and had reflected on how past practice may not have fully supported people to fully lead happy, healthy and meaningful lives as described in the provider’s purpose. The provider's policies were in line with current best practice, however we found they were not always followed in relation to the management of incidents and distress, risk management and infection prevention and control. Staff and leaders did not always demonstrate a positive, compassionate, listening culture that promoted trust and understanding

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.

The Registered Manager had been at the service for many years and knew people and staff well. The provider and the service were in the process of implementing significant changes to the culture within the service and the way care, treatment and support were delivered. The Registered Manager was open to these changes and was working hard to learn and improve to support and lead the staff team to deliver these changes. However, concerns were identified with the lack of management oversight and systems and processes to effectively monitor and mitigate risk and improve quality of life for people using the service.

There was at times a lack of senior leadership support and oversight resulting in delay in addressing shortfalls identified by staff and the registered manager, in particular concerns about the premise sand environment.

Staff could contact senior managers, there was an on-call rota to ensure a senior manager was always available.

Staff said they felt supported by their manager and felt able to raise concerns. The provider had a policy to support this. Information for staff about who to contact if they had a concern was available to them. However, we were not assured staff always recognised or understood when best practice was not followed, in particular with regards to the management of incidents and distressed behaviour.

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 had an equality diversity and inclusion policy. Staff job descriptions included expected behaviour by staff to uphold the providers commitment to equality and diversity for all.

The provider did not have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

There was a programme of audits to check standards of compliance with the providers policies and procedures and to promote people’s safety. However, audits had not been effective in identifying the concerns we found during this inspection. Health and safety audits had not identified hot water recording errors or third floor windows without restrictors and this put people at risk of harm. The fire risk assessment had not identified staff concerns about identifying the source of the fire alarm when it sounded and there was no floor plan in place to aid effective evacuation in the event of an emergency. Infection prevention and control audits had not identified areas of the service which were visibly unclean or that staff did not follow cleaning schedules as described in the providers own policy and within national guidance. There were ongoing issues within the premises and environment which meant people lived in an unappealing poorly maintained environment. This was despite relatives and staff raising this as an issue that required action form senior leaders. A relative said, “There are definitely issues with general maintenance issues, things do not seem to get done and head office should be a lot quicker in sorting requests out.”

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. However, information recording and may result in professionals not having the required information for review.

The Registered Manager made appropriate referrals to external health and social care professionals where this was required for people. They followed advice and action plans provided by healthcare professionals and commissioners.

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

Staff told us they had regular staff meetings and handovers where they discussed incidents and shared learning opportunities to ensure staff are updated. However, the provider had not ensured learning and improvement regarding positive behaviour support and the management of incidents and distress. There was a lack of oversight and review of incidents, this meant action to identify triggers and to take action to reduce further risk was not always taken or was not effective. The provider was in the process of transitioning from one positive behaviour support methodology to another. Staff had received additional training to ensure people could be supported safely. This new practice and ways of working required further time to become fully effective, embedded and understood by staff.

The provider did take swift action to remedy some of the immediate risk in the environment we pointed out during our site visits.