Allfor Care Croydon

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

This key question has previously been rated good. This inspection has rated Inadequate. This meant people’s needs were not met through good organisation and delivery.

The service was in breach of legal regulations in relation to person-centred care, receiving and acting on complaints and dignity and respect.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us the provider was disorganised and did not respond to their concerns, calls were late, carers changed frequently, and individual care needs were not being met.

The service did not consistently work in partnership with people to decide how to respond to changes in their care, and people did not always receive support when they wanted it. For instance, a person reported disliking being supported to bed at 5 pm. A review of their records showed a pattern of inconsistent call times delivered both before and after their preferred time. When challenged, the registered manager acknowledged the operational difficulty in scheduling the final call for every individual but committed to review and adjust call times for people with specific bedtime routines and preferences.

People or their representatives reported they were not involved in their care planning. A person commented, “There doesn't seem to be a proper plan for how her care should work today and it is really not difficult.” Another person, whose plan was electronic, stated, “The care plan is all electronic, so I have no idea what is in it.” These comments demonstrate the service failed to ensure people understood or had input into their own care arrangements.

A significant barrier to involvement was the lack of access to care plans. Multiple people and their representatives reported that they did not have a copy of the care plan. Furthermore, the electronic software application intended to give people and relatives access to view care plans was not working. The registered manager confirmed this failure, stating they did not know when the software issue, which had been reported to the company, would be resolved.

This lack of access meant the service failed to provide opportunities for people to be involved in making decisions about their care. A person highlighted the unilateral decision-making process, commenting, “It (the use of electronic care plans) was all arranged without any discussion, it just happened.” This demonstrated that people were not consistently consulted or given access to their essential care information.

Care was not always joined-up, flexible and did not consistently support choice and continuity. Whilst some people spoke positively about the regularity of their care visits, most of the feedback received suggested this was not everyone’s experience. Comments received included, “There’s no communication between visits. They (care workers) turn up at random times without any idea what’s happened before” and “It’s been five months since they started coming and their timing is hopeless, often I don’t know if they’re going to turn up at all. I rarely get a call to say when (or if) they’ll arrive.”

The service failed to consider the significant negative impact a lack of care continuity had on people, especially those with specific needs like dementia and learning difficulties. For example, a person living with dementia was attended by 16 different care workers over an 8-week period, with 9 different workers in just the first three weeks. This inconsistency created distress and forced the person's relative to formally request consistent care staff, a request the provider failed to even acknowledge. The calculation reflects the number of distinct staff entering the home, as experienced by the person. The provider has since explained that some attendances were shadow or training visits; however, this was not clearly recorded or communicated and had a negative impact on how the person experienced care.

The provider's inaction worsened the situation, as an additional 12 different care workers were assigned over the next seven days despite the formal request for stability. This constant turnover compromised the person's privacy and dignity, as they and their representative had to repeatedly explain their needs to each new carer. The service took no steps to improve this situation, thereby failing its responsibility to ensure better care outcomes.

This failure was systemic and affected other vulnerable people; another person living with a learning difficulty and who was non-verbal was seen by 7 different care workers over a three-month period. By not providing regular care staff, the service failed to meet the specific needs of people with learning difficulties and dementia, resulting in a damaging lack of choice and continuity crucial for their well-being. The person was non-verbal and, essential information contained in the initial assessment such as use of pictures or gestures was not transferred into the final care plan. This omission, combined with inconsistent staffing, meant staff did not always have the information needed to communicate effectively.

Since 2016 onwards all organisations that provide publicly funded adult social care are legally required to follow the Accessible Information Standard (AIS). The standard was introduced to make sure people are given information in a way they can understand. The standard applies to all people with a disability, impairment or sensory loss and in some circumstances to their care workers.

The provider did not supply appropriate, accurate and up-to-date information in accessible formats that were tailored to meet people’s individual care and support needs.

The provider had an ‘Achieving the Accessible Information (AIS) Standard (England) Policy dated 1 November 2024. However, the AIS policy was not always followed in practice. Initial assessments and care plans viewed but not all were not adapted into easy read to support people with different communication needs.This was cited in 2 care plans. This meant people were not always provided with information in ways they could understand.

The service failed to ensure people's concerns were always addressed, with many feeling their complaints led to no action. While some people felt managers listened, others reported dissatisfaction, with comments including, “She (family member) doesn’t feel listened to, and that upsets her” and “I do complain quite a lot, or nothing seems to get done.” The service's own ‘Concerns and Complaints Policy’ dated 27 November 2024 required all complaints to be investigated and proportionate action taken. However, verbal complaints were not responded to straightaway, with people reporting, “I have complained but I don’t get anywhere. I’m always on the phone to them (office staff), but they simply do not step up to the challenge”.

Management failed to consistently record verbal complaints in the register, and care records lacked documentation detailing how specific matters were addressed. For example, a formal complaint raised on 4 July 2024 (following verbal concerns on 25 June 2025 and 4 July 2025) about late/missed calls and management capability received no response until the inspection team intervened on 11 July 2025. Neither the verbal nor written complaints were documented on the service’s complaints tracker. People felt there was a lack of follow-up, stating, “I’ve complained more than once, but nothing ever seems to be followed up satisfactorily” and “There’s no follow-up after issues are raised.”

The complaints process itself was a significant barrier, especially for people unable to write a formal complaint for example due to medical conditions. The procedure required that unresolved verbal complaints be escalated to a formal written complaint, which involved a lengthy waiting period of up to 28 days for investigation. This process delayed appropriate action for identified service failures and lacked information on support available to assist people in making a complaint.

This did not offer a straightforward and accessible route for making complaints, with inconsistent information and contact details provided across various documentation.

The service failed to ensure equal access to services by not consistently considering and implementing reasonable adjustments for people, particularly those with learning disabilities and dementia. While care plans noted general required aids, they failed to incorporate essential person-centred adjustments needed to meet complex needs. This lack of focus meant critical elements like consistent routines, clear communication strategies, and continuity of care which are vital as conditions like dementia progress were often overlooked.

Where people had specific communication needs linked to their diagnosis of dementia or learning disability, there were no records documenting any visual aids people might use, and care plans were not written in an easy-read format. The service did not use communication passports, which would have equipped care staff and authorised personnel with immediate information on how people expressed their care and support needs.

Care plans did not prioritise the consistency and routine vital for people with learning disabilities and dementia to prevent distress and confusion. There was a lack of flexible scheduling and reliance on inconsistent staffing, which directly undermined the stability necessary for their well-being. These issues regarding continuity and staffing have been detailed in other sections of the report.

Although staff completed relevant specialist training, including dementia awareness training and mandatory learning disability training, the concerns identified during the inspection indicate this training was not effectively embedded into daily practice. The failure to translate learned knowledge into person-centred adjustments meant the service could not ensure people's mobility, communication, and sensory needs were being adequately met.

Initial assessments and care plans did not comprehensively reflect people's needs relating to their protected characteristics under the Equality Act 2010. Although care records captured race, religion, ethnicity, and preferred language, they failed to consider other key characteristics, including people’s sexual orientation, and marital status. By failing to assess the needs linked to all protected characteristics, the service was unable to guarantee people would be fully protected from discrimination.

Staff had received relevant training however some staff were unable to demonstrate an understanding of what protected characteristics were. For example, a care worker commented, “I am not sure what protected characteristics are if I’m honest” and a manager told us “I’m sorry I am unable to give an example of protected characteristics.” This meant we could not be confident people would always be protected from discrimination when accessing the service.

The service's systems failed to ensure staff were adequately trained for end-of-life care, as some staff reported not receiving this training despite the training matrix recording it as complete. This discrepancy meant the training logs were unreliable, and the service could not be confident care workers knew how to provide appropriate support to people at the end stage of life, placing people at risk of receiving inappropriate care.

End-of-life documentation, including critical decisions, was not always followed. For example, a complaint from a health and social care professional confirmed a person's Do Not Attempt Resuscitation (DNAR) choice was not followed when there was a deterioration in their health. This discrepancy meant the training logs were unreliable, and the service could not be confident care workers knew how to provide appropriate support to people who were actively dying, placing people at risk of receiving inappropriate care.