Archived: Bowland Lodge

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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At the last inspection we rated this key question requires improvement. At this inspection 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.

We found the provider was in breach of the legal regulation relating to the submissions of notifications, the service provider and good governance.

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 service did not have a shared vision, strategy or culture based on transparency, equity, equality, human rights, diversity, inclusion or engagement. Leaders did not understand the challenges or needs of people or the workforce. Staff were not able to describe a clear or consistent vision for the service, and there was limited understanding of how the provider’s values translated into day-to-day practice. Expectations were not clearly communicated, and this resulted in inconsistent approaches across the service. There was little evidence that leaders actively promoted an open or inclusive culture, or that people’s experiences and feedback were used to shape the direction of the service.

The service did not have inclusive leaders at all levels who understood the context in which care and support were delivered. The management did not embody the values of the organisation and did not demonstrate the skills, knowledge, or credibility required to lead effectively with integrity, openness, and honesty. There was no legal provider or registered manager. Staff, professionals, relatives and people had all understood the partner’s son was the owner, which was incorrect. The management team was not consistently visible or accessible to staff. Staff feedback did not demonstrate confidence in leaders’ decision-making or their ability to support and guide practice. There was limited evidence that any management team engaged meaningfully with staff or modelled compassionate and inclusive behaviours, which negatively impacted staff morale and consistency of care delivery.

Staff did not feel they could speak up or that their voice would be heard. Staff were not confident to raise concerns with the management team and felt any issues would remain unresolved. Staff feedback indicated that they did not feel safe raising concerns or challenging poor practice. There was limited evidence of effective systems to encourage open dialogue, and staff were not confident that issues raised would be acted on without negative consequences. This contributed to a closed culture where learning and transparency were not promoted. A staff member said, “There’s not enough staff to complete the work. I do not feel risk is managed safety and effectively. Enough training is not provided to assist me. I also do not feel my views are listened to.”

The service did not always value diversity in their workforce. There was limited evidence that equality, diversity and inclusion were embedded into workforce practices. Staff were not consistently supported through reasonable adjustments, and there was a lack of assurance that policies were understood or applied consistently. The management team did not routinely seek or use staff feedback to understand the experiences of people with protected characteristics.

The service’s governance systems continued to be ineffective. The service did not always have clear responsibilities, roles, systems of accountability or effective governance. The management team did not always act on information about risk, performance and outcomes to ensure sustainable, high-quality care. They had not identified the service continued to fail to meet the requirements of the regulations and no improvements had been made to the service since our last inspection visit.

We also had concerns about their financial viability as the service was not paying staff correctly or on occasions at all for the hours they worked. Staff pensions had not always been paid. Staff could not access any online training because the fees for this had not been paid. The partner’s son stated they were slowly replacing defective fire doors because of financial constraints. However, white goods such as broken dishwashers, dryers, medicine fridges were not being replaced. Staff were routinely told to ration washing powder and other cleaning products. All of which suggests the service struggled to cover their costs and operate the service.

The service did not always understand or meet their duty to collaborate and work in partnership, and services did not always work seamlessly for people. Information sharing with external partners was inconsistent, which affected continuity of care. Leaders did not consistently demonstrate how learning was shared or how partnership working was used to improve outcomes for people. Opportunities to strengthen collaboration with community and health partners were not always taken.

The service did not focus on continuous learning, innovation and improvement. They had not ensured there was a system in place to encourage continuous learning, innovation and improvement across the service. Audits were often missing or incomplete and therefore staff could not ensure everything was working in line with requirements. There was limited evidence that learning from incidents, concerns or feedback led to sustained improvement. Systems for capturing learning were weak, and staff were not consistently supported to reflect on practice or contribute ideas for improvement. As a result, repeated issues were not effectively addressed and improvements were not embedded.