Alderlea 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 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 in relation to governance and oversight of the service.

This service scored 61 (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 manager described key priorities as ensuring people were happy, safe and treated with dignity and respect, and staff observations demonstrated caring interactions and a person-centred approach. The provider had systems in place such as staff meetings and feedback surveys to encourage the involvement of people, their relatives and staff. However, these did not appear to be held regularly, and it was unclear how feedback had been used to drive improvement in ways that mattered to people. Despite this, people and their relatives were positive about the culture of the service. One relative told us, “I would recommend this home because the staff are caring, friendly and it seems family-oriented and relaxed."

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. The manager was visible and approachable, and staff told us they were supportive, and were easy to talk to. However, the non-completion of audits limited their ability to make timely and effective decisions, monitor performance and provide clear oversight of the service. The manager showed a commitment to improving the service and was receptive to feedback. During the assessment, concerns we identified were acted on, including environmental issues and health and safety concerns.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People working at the service were able to raise concerns and reported being listened to. A staff member told us, “I have raised a concern, and it was listened to and action taken." This demonstrated processes were in place to support speaking up.

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 promoted workforce equality, diversity and inclusion. Records showed the service completed relevant employment checks, health declarations and assessed whether reasonable adjustments were needed as part of recruitment processes. Staff told us they felt valued and supported in their roles. One member of staff said, “I am valued and supported. If I have any issues, they are dealt with immediately." Another staff member reported they felt treated fairly and were supported when concerns were raised.

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's governance and quality assurance systems were not operating effectively. Regular audits had not been consistently completed, which meant concerns had not been identified or addressed in a timely way. There were gaps in the oversight of clinical risks and medicines management, and there was no evidence that incidents and accidents were being analysed. As a result, opportunities to identify trends, learn from events and make improvements were missed. Records did not consistently demonstrate that people were receiving safe and effective care. We also found concerns relating to fire safety. Fire safety records were not available, and the provider was unable to provide evidence that recent fire drills had taken place. These issues meant there was insufficient assurance that people and staff would be able to respond effectively in the event of an emergency. We requested that drills were completed immediately to provide assurance that appropriate fire safety arrangements and emergency preparedness measures were in place. The manager completed this and sent us the completed records.

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. The service worked with a range of external partners to support people's care and wellbeing. Relatives described access to healthcare professionals including agencies to support people where risks had been identified. People benefited from links with the wider community through visiting groups, local schools, entertainers and animal visits. People and their relatives spoke positively about these opportunities and the impact they had on their wellbeing. A relative told us, “It’s a warm, friendly and cheerful home."

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. The service showed willingness to improve, and the new manager had identified some areas which required action. During the assessment, immediate improvements were made in response to concerns raised, including kitchen cleaning records, environmental risks and fire safety arrangements. The manager told us about their plans to improve the environment and support people to identify their rooms more easily. However, systems to support continuous learning and improvement were not effective. Governance records showed audits had not been completed consistently, incidents and accidents were not being analysed for trends, and lessons learned were not always demonstrated through service-wide improvement activity. Leaders were taking steps to improve the service, but there was limited evidence to demonstrate that these processes were embedded throughout the organisation.