Alchita Care Limited of Bradford

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 29 (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. There was no statement of purpose or improvement plan in place. The was no evidence the service’s shared vision, values or goals were shared with staff, and we found systematic and widespread failings in the management of the service, which meant the provider did not facilitate an effective learning culture. The registered manager did not demonstrate the required capability to deliver person centred care or to ensure risks were well managed.

The provider did not have inclusive leaders who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Although staff spoke highly of the leadership team, we found leaders did not have the skills, knowledge, experience and credibility to lead effectively. The provider and registered manager did not demonstrate an understanding of the CQC requirements and information was not readily available during the assessment. We were therefore not assured there was effective oversight in the service. Team meetings were not held regularly, and leaders did not ensure staff were kept up to date with relevant changes.

People did not feel they could speak up and that their voice would be heard. Although the provider told us there had been no complaints in the service, we were not assured processes in place would ensure complaints would be handled appropriately. There was no complaints policy in place. The provider failed to ensure there was communication to staff, people and relatives regarding how to raise concerns. Staff meetings did not evidence staff had been given the opportunity to speak up and drive improvement. Although there were recent surveys completed for staff and people using the service, there was no evidence of action taken in response to feedback given.

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider could not evidence how they supported staff with their wellbeing. Staff supervisions were not completed regularly, lacked details and did not evidence meaningful conversation. There were no policies in place to support staff for example; around gender pay gap, equality and diversity. There were no policies or processes in place to promote workforce wellbeing.

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. Processes in place did not support good governance. During the assessment there were systematic and widespread failings in the management of the service. The provider failed to ensure the quality of care, and the service provided was effectively monitored and assessed. There were no effective measures in place to improve the quality and safety of the services provided. For example, audits were not readily available and did not identify the issues we found during assessment. Where actions had been identified from audits, there was a lack of oversight to ensure these were managed and completed. Care records were inaccurate, meaning staff could not rely on them for guidance. Systems for managing accidents and incidents were not implemented robustly. As a result, themes and trends were not identified to support learning and drive improvements in people’s care. Additionally, key policies and procedures were not in place.

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. Feedback from external professionals highlighted concerns. We were provided with evidence of an external professional requesting information regarding a safeguarding concern from the provider which was not received. Care records did not demonstrate collaborative working with external professionals. There was no evidence of participation in local forums, groups, or schemes. No meeting records were available to demonstrate that shared learning had been discussed. There were no policies in place to support collaboration and continuous improvement.

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 was no effective system in place to measure and evaluate the service to ensure its outcomes were consistently positive and safe, and that all reasonable steps had been taken to mitigate risk. The provider failed to ensure people, relatives, and staff were involved in developing and improving the service. The audits in place did not support learning and meaningful improvement, and there was no overall action plan for the service.