Allfor Care Croydon

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 regulations in relation to good governance, duty of candour and statement of purpose.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The management team told us the service had a positive culture focused on providing high-quality, person-centered care. They believed they were fair to people and actively addressed challenges like cultural and language barriers through team discussions and provided ESOL (English for Speakers of Other Languages) classes for staff.

Staff described a culture of collaboration, open communication, and support. Some felt their voices were heard, which they believed promoted learning and improvement. However, this positive view was not supported by feedback from people who used the service and their relatives or by concerns found during this inspection.

People expressed concerns about the service's culture, citing several issues that made them feel excluded or disrespected. Key examples included care workers speaking in their native language in front of clients, perceived rudeness, and frequent lateness. We found no evidence to show this feedback was documented in service user feedback questionnaires and quality monitoring visits. Therefore, we were not assured appropriate action was taken to address them.

Minutes of staff meetings both with office-based staff and care workers, did not document discussions about the service’s visions, values and strategic goals. There were no documents to show the mission and objectives as outlined in the service’s statement of purpose (SoP) was understood by all staff and met.

Management's lack of visibility and contact resulted in mixed views regarding their compassion and engagement. While some people felt management was compassionate, others felt they had no one to turn to for help or to raise concerns due to poor communication from leadership. This was supported by comments from people who stated they did not know who the managers were, had never been introduced to them, or had a way to contact them.

Staff members' views on leadership were similarly divided. Some staff described leaders as having strong communication and listening skills, being compassionate, and "hands-on." They also credited leaders with acting quickly to address concerns about a poor culture and its impact on care quality.

However, other staff members expressed a less certain view, feeling they received more direct support from allocation officers than from managers. This uncertainty was reflected in neutral comments such as, "I think they (management) are ok" and "I could not say they (management) are not supportive, but I could not say they are." This indicated a lack of clear and consistent support from the service's leadership, creating ambiguity about their involvement and reliability.

Recruitment and induction for a newly hired leader showed systemic issues that raised concerns about governance. The provider failed to maintain clear and accurate records, as evidenced by discrepancies in the job title between the application, the interview questionnaire, and the final work contract, questioning the clarity of the role from the outset. There was no programme of induction in the new leader's staff file, meaning the service could not confirm whether a comprehensive, structured, or tailored induction was provided to prepare the leader for their responsibilities.

Staff confidence in management's responsiveness and confidentiality was mixed. Some staff felt comfortable reporting concerns, citing prompt action on issues like staff lateness with investigations and spot checks. However, others lacked confidence, fearing repercussions because they believed management did not always maintain confidentiality when listening to concerns.

The service's actions did not support management's claimed open culture. The registered manager denied recent whistleblowing allegations but did state issues were taken seriously and shared for learning. Meeting minutes showed whistleblowing was not consistently discussed at team meetings.

There was no evidence that recent whistleblowing concerns regarding staff training and care plans, were discussed or that staff were given an opportunity to respond. Minutes only informed staff of the procedure and contacts, highlighting a gap between management's claims and actual practice.

The failure to address issues objectively created a working environment that discouraged staff from speaking up, fostering a potential for a closed culture. While the ‘Whistle Blowing Policy’ provided external reporting contacts, the inability to act on internal concerns undermined its effectiveness.

Staff gave feedback when discussing if they were treated fairly. Comments included, “No, because I am not given assurance, they (management) have my interest”, “I feel that I am treated fairly. I have not experienced any mistreatment” and “The office offered time off (after a period illness), I felt good when they told me to rest up and I had extra shifts to cover days I have missed.”

While the Quality Assurance Manager confirmed Christmas was celebrated with people and staff members, we were not informed of any other celebrations or observances for diverse religious, cultural, or other festivities. The provider missed an opportunity to demonstrate its culture was genuinely inclusive and met the holistic needs of all people who used the service, people who were important to them and their staff members.

The service had an Equality, Diversity and Inclusion Policy and Procedure dated 9 June 2025, along with a separate discrimination policy located in its statement of purpose (SoP). However, its approach to promoting equality in the workplace was inconsistent and fragmented. While the staff handbook, referred to equal opportunities, the overall focus of the documentation was on protecting people who used the service from discrimination. While there were some references to ensuring a fair recruitment process for staff, the service lacked a specific, overarching workforce equality diversity policy to govern its practices, leaving a significant gap in its commitment to being a truly inclusive working environment.

People’s feedback about service’s leadership was overwhelmingly negative. Many reported missed, late, or no-show care visits, with comments such as, “There’s no strong leadership, it’s all reactive,” and “Management doesn’t seem to be on top of what’s happening.”

The service’s quality assurance systems were largely reactive and failed to identify or address persistent issues, including missed calls and poor record-keeping. Staff meetings held on 21 March 2025 and 29 May 2025 highlighted these issues but lacked follow-up, preventing systemic change and accountability.

Complaint handling was unreliable. Several people reported raising concerns repeatedly without receiving a response. One person stated, “I do complain quite a lot, [but] nothing seems to get done.” This was reflected in the “Quality Monitoring Monthly Audit” dated 7 April 2025, which recorded 16 satisfied and only 2 dissatisfied service users, yet also listed multiple complaints, contradicting the summary satisfaction data. This demonstrates that the complaints register did not accurately record the number of complaints received.

Poor record-keeping was widespread, with documents often illegible, incomplete, or inaccurate. One person noted, “The admin behind the carers need to work on their processes because there are too many gaps.”

There was a consistent lack of candour. The provider did not supply the necessary written evidence of apologies or outcomes related to notifiable incidents, as required under Regulation 20 – Duty of Candour. Transparency issues extended to management, with information about operational practices, such as the use of company vehicles for care workers, being contradicted by internal records.

The service experienced significant governance lapses, including a data protection breach involving the incorrect handling of personal data and a failure to maintain its Scheme of Delegation, which led to unclear accountability for key management roles.

These findings demonstrate systemic weaknesses in leadership, governance, complaints management, record-keeping, and candour, which underpin the assigned rating and regulatory breaches.

The provider had submitted a provider information return (PIR) on 4 July 2024 which we reviewed before this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make.

The PIR stated the service partnered with specialist services such as dementia specialists and tissue viability teams. Whilst the service did attend multi-disciplinary meetings with health and social care professionals, the care plans reviewed for people with these needs, did not demonstrate such specialist input had been incorporated. Therefore, we could not corroborate the PIR claims within the sample reviewed.

There were systemic issues with learning which resulted in significant gaps in how the service’s quality assurance systems operated. For example, training was not being embedded into practice and this led to inconsistencies in the quality-of-care people received.

Lessons were not always learnt as some peoples’ experiences of care and support were affected due to late, missed and no-show calls. The service’s monitoring systems did not enable the registered manager to identify common issues to help them to make service-wide improvements.

Staff were not always held to account when staff members’ and procedures were not always effective in creating changes in staff member’s poor performance. We saw evidence of staff spoken with and reminded of policies after a complaint, although no plan to review improvements or changes happened and were maintained.

After our inspection, the provider shared an improvement plan which addressed some of the concerns found during our assessment. We will follow this up at the next assessment of the service.