Alderwood L.L.A. Limited - Irchester

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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, this limited opportunities of learning from incidents and ensuring people remained safe from harm. 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.

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.

Staff understood the values of the organisation and what they want to achieve for people. However, Staff told us there was limited opportunities for people who live at the service due to their needs. Staff said they were scared that incidents might occur if they tried new things with people. One staff member told us “We took [Name] out shopping for clothes and for food, but they stayed on the bus the whole time because it’s safer. I don’t think they could go in a big shop, its too risky” There had not been consideration about how to increase the person’s opportunity to be involved in a way that mitigated risks.

The provider had a vision and values statement, and this was displayed within the service. Staff meeting records evidenced a shared direction and values of the service were discussed with staff. For example, a staff meeting was held in October 2024 which 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. There was a culture of adverse risk mitigation which did not allow people to try new things out of the scope of already safe activities. The lack of positive risk-taking meant people lacked opportunities to develop and maintain skills and experiences and ensure person-centred activities were meaningful and purposeful. 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, if there were any learning to reduce re-occurrence were not formally completed. This meant there were missed learning opportunities for behaviours of concern had not been completed and incident debrief meetings to review what happened and opportunities to understand and learn from incidents, raising concerns about the culture of the service and increasing the risk of harm.

Staff spoke highly of the new registered manager and commented on the changes and improvements already made since their appointment. A staff member told us, “The new manager is a very good leader and has made a lot of changes. Since they started, we have learnt a lot more and we learn from the tasks they ask us to complete. The manager is very new to the service, but if the manager listens to us, things will only improve more so” However, staff teams lacked knowledge of who and how to contact management teams in the event the registered manager was not onsite. This meant relevant incidents and concerns were not always reported or actioned in a timely manner.

The Registered Manager was new to the service at the time of the assessment. However, they had made several improvements since their appointment, such as reducing restrictions within the service and developing Mental Capacity care records for staff in an easy format. The manager had developed a positive and professional relationship with staff teams, relatives and professionals. However, concerns were identified with the lack of management oversight and systems and process which impacted staff ability to have access to management support when needed. However, concerns were identified with the lack of oversight and ineffective systems and process impacted both the registered manager and staff ability to have access to management support and specialist advice when needed. Staff had been recruited safely following expected checks and requirements.

Some staff told us they felt listened to and could approach the registered manager if they needed to. However, some staff told us they had raised concerns previously and no action was taken. One staff member said, “I have raised concerns with both old and new manager, but I have had no response,” another staff member said, “I've spoken up before and it did go to the shift leader. I didn't like what I saw. I don't think any action was taken and I didn't get any feedback for what I raised. I don't think anything came of it. But if I needed to, if I didn't like the answer, then I would go back to the manager.”

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 whistle-blowing 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. However, we were not assured all staff understood their responsibility to report concerns and how to escalate these to managers to keep people safe.

Staff told us they felt they were treated fairly and equitably. One staff member told us, “We make sure everyone has a treat on their birthdays to make them feel included. Flexibility is good, we can be flexible for the staff covering rota - some staff only want to work the weekends and others working all week ensure we support the needs of staff where we can.”

Staff were 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. However, staff safety and well-being was not effectively responded to or monitored by the management team. A lack of systems and processes to ensure staff teams were supported following significant incidents had not routinely been completed. Where debriefs had been undertaken with staff, there was a lack of information recorded to ensure the safety of staff teams or staff training, and development opportunities were not highlighted or actioned.

There was mixed feedback from staff regarding the management and sustainability of the service. Some staff were unclear on the reporting process and felt senior staff members didn’t escalate their concerns when raised. One staff member told us, “Service is good, it’s alright not perfect, in two minds because of changes in last 2-4 years there has been 3 managers, we report to the senior if there isn’t a manger on site.”

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 analysis of what had occurred. The provider’s incident management electronic system did not provide relevant information to ensure a functional assessment of distressed behaviours was effective. This only happened when a need for a full behavioural assessment had been identified by the registered manager and positive behavioural team. There had been a significant incident involving a person at the service in May 2024. 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 re-occurrence. Some governance processes were ineffective. The provider’s monitoring systems had not identified the shortfalls identified in people’s care plan guidance where information lacked detail or was missing. Neither did they identify missing mental capacity assessments and best interest decisions.

Relatives confirmed they were involved in peoples care reviews. However, there was a lack of referrals made to health care professionals to ensure the right people were involved in people’s care to keep people safe.

Staff told us they work closely with health care professionals and commissioners. One staff member told “it’s better now we have people visit the service. They get better care as they consent, we record the appointment and report changes” However, we were not assured staff ways of working were inline with best practice as advocated by health professionals.

External professionals raised concerns with the service sharing relevant information with them. This included changes in people’s routines and commissioned hours.

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. The registered manager was undertaking a review of people’s care records and had identified a lack of relevant health professional oversight. This included services such as SALT. (Speech and language team) However, at the time of this assessment people were still waiting to be assessed to manage individual health risks and staff lacked guidance on effective support to mitigate individual risks to people.

Staff told us they have regular staff meetings where they discuss incidents and share learning opportunities to ensure staff are updated. However, staff could not tell us if this learning was then embedded in staff ways of working and if these are monitored or reviewed. One staff member told us “We have meetings and discuss what we need to learn or change, but you go off for a few days and come back and are working with different people and things change”

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 throughout the assessment, this highlighted the inconsistency across staff skill, training and knowledge to ensure people could be supported safely. 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.