Alderwood L.L.A. Limited - Irchester 2

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• 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

During our assessment of this key question, we found concerns in the governance systems and processes that monitored the quality and safety of the service. This resulted in a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below. The systems and processes in relation to incident management was not sufficiently robust. The provider’s policies and procedures were not always followed, and management oversight had not been fully effective. Whilst there was a shared direction and open culture, this was impacted upon by limited opportunities of learning from incidents. Staff were positive about working for the provider and complementary about the management and leadership of the registered manager. Staff felt confident they could raise any concerns and were respected and listened to. Diversity and inclusion were promoted within the service. There was positive partnership working with external professionals and people were supported to access community opportunities.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff were aware of the providers vision and values statement and were positive there was an open and transparent culture. A staff member said, “Everyone helps each other, we work as a family and can be supported if unsure of anything.” Another staff member said, “The manager is fair and approachable. I quite like working there because if anything happens will come together to find a solution.” However, there was a lack of evidence to confirm what discussions had been had with staff about learning opportunities and development of the service.

The provider had a vision and values statement, and this was displayed within the service. Staff meeting records / memos evidenced a shared direction and learning culture. For example, a memo dated October 2024 informed staff of how blanket restrictions had been removed and guidance provided about how any restrictions needed to be individually assessed. However, the quality of audits and actions in relation to learning from incidents found shortfalls. The provider's policies were in line with current best practice, but we found they were not always followed in relation to incident management processes. For example, risk assessments for behaviours of concern had not been completed and incident de-brief meetings to review what happened and if there were any learning to reduce reoccurrence were not formally completed. This meant there were missed opportunities to understand and learn from incidents, raising concerns about the culture of the service and increasing the risk of harm.

Staff were positive about the management and leadership of the registered manager. They told us the registered manager had an open door policy and was always available for support and guidance when on duty or off duty. A staff member said, “The manager honestly, hands down is the best, she listens, she cares, you can raise any issues, and she will take them on board and will respond positively, she's very supportive.” Staff described staff morale as being positive and how there were opportunities for staff to develop and be promoted to different senior care positions. A staff member said, “Yes, if wanting to progress to shift leader, you need to complete Level 2 care, the course would be put in place and once confident to do that role and then an interview with the manager.” The registered manager told us about the importance of them being open and honest with others and how they instilled this within the staff team.

The registered manager was experienced having worked at the service for a number of years. They demonstrated a good understanding of people’s individual needs and was clearly liked and respected by both staff, people using the service and relatives. The registered manager had also developed a positive and professional relationship with external professionals. Whilst staff had not received supervision at the frequency the provider expected this was being addressed, and the registered manager had an open door policy and made themselves available to staff. The provider was in the process of implementing spot checks to formally review staff practice. Staff had been recruited safely following expected checks and requirements.

Staff were aware of the provider’s policies and procedures that supported them to raise any issues relating to poor practice, concerns and complaints. Staff told us they felt confident they could use these procedures, and they would be listened to, and managers would take action. A staff member said, “Yes, everyone has the right to feel comfortable to raise concerns. I feel comfortable raising concerns and making suggestions and we get verbal feedback.”

The provider had systems and processes in place for staff to report any concerns of poor staff practice. This included policies and procedures such as the whistleblowing and a freedom to speak up. Staff were also enabled to share any concerns via staff supervision meetings and the registered manger had an open door policy of making themselves available to the staff team.

The service benefited from a diverse workforce, which promoted equality and diversity. People had the opportunity to be supported by staff from similar cultural backgrounds. Staff were positive about working for the provider and was complementary about the management and leadership of the registered manager. Staff confirmed the registered manager was fair, treated them equally and they had not experienced any form of discrimination. A staff member said, “What's good working here is the environment, the atmosphere, we have a good team, staff work well together. We have good communication, there's a blend of different staff with different skills and experience. The rota reflects staff skill mix and experience well. I feel the voices of people we support are heard.”

Staff were protected and respected by the registered manager. The provider had policies and procedures available to staff that protected their human rights and working conditions. The staff rota considered staff’s shift / work pattern preferences. Staff received opportunities to share their experience about working for the service via an annual feedback survey. Staff meeting records showed how staff were encouraged and enabled to raise any concerns.

Staff were clear about their roles and responsibilities and were accountable for their work. Staff gave examples of their duties and were aware of the staff structure. Staff told us about the internal communication procedures to share important information. A staff member said, “Staff meetings are every month, If there is something important the manager will be put in the communications book to be read and signed by staff, kept in shift leading office.” However, we were not sufficiently assured staff were fully fulfilling their role and responsibilities in how incidents were managed, including the recording and reporting of incidents.

The provider’s systems, processes and procedures in how risks associated with people’s distressed behaviours were assessed, reviewed, monitored and mitigated were not sufficiently robust or fully effective. This put people, including staff at increased risk of harm. Incident records reviewed were poorly recorded, with limited information to support a robust understanding of what had occurred. We identified two significant critical incidents that should have triggered a full behavioural assessment, but this had not been picked up. This showed a lack of effective monitoring and management oversight. The absence of effective monitoring systems in relation to incidents means the service failed to identity the poor quality of reporting and missed opportunities to properly investigate, learn lessons, review the person’s care plans and prevent reoccurrence. Staff supervision records identified staff had not received supervision at the frequency the provider expected. Whilst action was being taken to make improvements, this put people at higher risk of receiving inappropriate care and support. A lack of staff supervision meant staff had not received formal opportunities to discuss their work training and development needs. Whilst there were staff communication methods such as a daily handover, staff meetings and care records to share important information with staff; records reviewed showed limited learning opportunities. Whilst the registered manger and staff told us there were discussions about learning, there was no evidence of this, we were therefore not fully assured. There had been a delay of five months in environmental repairs being completed to a person’s bedroom window, radiator and ensuite following a behavioural incident. Whilst the registered manager told us and records confirmed, they had regularly followed this up with head office to get this issue resolved, the length of time was unacceptable.

Relatives were positive about how staff worked with external professionals in the ongoing care of their family member. An example was given of partnership working between staff and external professionals as a result of a decline in a person’s health. Relatives confirmed their family member was supported to participate in social, leisure and recreational community opportunities and activities. People told us of the activities indoors and community they participated in and how they were happy with these. This included for some people attending the provider’s gardening and farm project, leisure parks and facilities, day trips, shopping, local walks and parks and participation in festivals and celebrations.

Staff gave examples of partnership working, this included working with external professionals such as the GP, psychiatrist, social workers and members from the intensive support team that consisted of specialist learning disability nurses and occupational therapists. Staff were positive about partnership working.

External professionals were positive about how well staff worked with them and followed any recommendations made. Professionals told us staff assisted them on their visits and shared important information to support them, clearly demonstrating good knowledge and awareness of people’s individual care and support needs. External professionals confirmed how people were supported by staff to access community activities and facilities. External professional feedback about the service was sought from the provider. Feedback received from an external professional reviewed in relation to staff and the registered manager said, “Communicates effectively with outside agencies where needed. Supports service users with empathy, respect and provides excellent care. Consistency amongst staffing."

Care records confirmed communication, liaison and referrals to external health and social care services for further assessment, support and guidance in meeting people’s ongoing needs was happening.

Overall, staff were positive about opportunities of learning and improvement. Staff felt able and supported to make suggestions and ask questions. A staff member gave an example of raising a concern about a deterioration of a person’s mental health as this was a worry and concern to staff, they told us of the positive response and actions taken by the registered manager. The regional manager told us how registered managers from across the provider’s organisation came together on a regular basis to share information and leaning. Staff were confident that people using the service and relatives were also involved and consulted about improving the service. However, we found there was limited evidence to show learning, improvement and innovation was regularly discussed with staff.

The provider had quality assurance systems and processes to seek feedback. However, records dated September 2024 of feedback from people, recorded how staff had identified some of the survey questions were difficult for people to understand therefore were not able to fully respond. The provider’s audit completed 30 September 2024 had not identified this shortfall and the management team had taken no action to make improvements. This meant we were not fully assured people were effectively supported to give their feedback about the service they received. Staff meeting records reviewed found a lack of discussion and actions in relation to learning, improvement and innovation sharing. The provider’s audit dated September 2024 identified team meetings needed to include specific discussion and recording of lessons learned. Whilst we saw the staff meeting record dated November 2024 included reference to lessons learnt, this needed further time to become fully embedded and sustained. We were aware the provider was in the process of transitioning from one positive behaviour support methodology to another. This meant staff were undertaking additional training. This new practice required further time to become fully effective and embedded in new ways of working. A review of the provider’s systems and processes that monitored and reviewed incidents, identified a shortfall in the effectiveness of the monitoring and oversight procedures in how lessons were learnt. We recognised the provider was in the process of reviewing some aspects of incident management procedures to make improvements, however, we were not provided with details and timescale of this work and therefore were not fully assured. The provider had a colleague nomination recognition award. Every month a colleague could submit nominations for members of staff they felt had gone above and beyond their normal job role. The winner from each of the services received an additional bonus in their monthly wage.