Howlish Hall Residential Care Home

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 inspection we rated this key question good. 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.

The service was in breach of legal regulation in relation to:

Regulation 17, Good governance

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not demonstrate a shared vision or strategy that promoted transparency, equity, equality, human rights, diversity, inclusion, or meaningful engagement. There was no clear leadership culture embedded within the service, and no evidence that the provider had a strategic understanding of the challenges faced by the service or the needs of the people and communities it supports.

There was a lack of provider oversight. There was no formal evidence that the provider maintained regular contact with the service, reviewed quality or performance data, or took steps to ensure the service aligned with the provider’s values or responsibilities. As a result, the service was operating without effective direction or accountability at provider level.

Our findings during this assessment did not demonstrate that leaders had the capability to ensure high-quality care was delivered or that risks were effectively managed. We identified shortfalls across several key areas, including governance procedures, infection prevention and control, safety of the premises, the quality of people’s care and support, and the maintenance of accurate records.

Although a home improvement plan had been in place since December 2024, the actions taken had not led to the necessary improvements. As a result, the service continued to fall short of delivering safe, effective, and responsive care to people.

An effective system was not in place to ensure staff were actively encouraged and supported to raise concerns or speak up. Staff did not have regular access to one-to-one meetings or team discussions where they could share ideas for improvement or feel empowered to voice concerns about the service. When asked about the management of the service and speaking up one staff member told us, “We don’t not get enough supervision. Last supervision I had was a few months ago. I do not feel supported.”

Policies and procedures intended to promote whistleblowing were out of date. The documents reviewed had been written in 2017. While a review sheet was present with signatures from previous managers, no amendments had been made. We could not be assured that these policies reflected current legislation, guidance, or best practice.

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Policies and procedures intended to promote an inclusive fair culture relating to equality and diversity were out of date. The documents reviewed had been written in 2017. We could not be assured that these policies reflected current legislation, guidance, or best practice.

During the discussion, the manager explained that the values of the service needed further development. They emphasized the importance of staff working collaboratively and mentioned that the current staff skill mix was under review. They recognised the need to develop a more inclusive workplace culture that supports and values all team members equally.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The did not have effective systems in place to enable them to have a robust oversight of the quality of the service being provided and to identify and assess risks to health and safety. We reviewed quality assurance systems in place. There were no structured provider-level checks in place to ensure the provider, had appropriate oversight of the service or to monitor that the service was meeting regulatory requirements. The manager confirmed they were not aware of any provider audits. Without a robust quality assurance framework, the provider was unable to identify risks, drive improvements, or ensure compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We reviewed the Business Continuity Plan dated 18 November 2024, which stated it should be reviewed yearly or when any alterations occur. This placed people at further risk of harm in the event of an emergency.

The current environmental audit was not effective. Areas identified as requiring urgent repairs had not been completed making the environment unsafe.

We reviewed the provider’s policies and procedures. These were originally written in 2017 and were not updated. Although signed to indicate they had been reviewed, there were no amendments to reflect any changes in legislation or updated best practice guidance. As a result, we could not be assured that the policies currently in use contained accurate, up-to-date legislation or reflected current best practice. This presented a risk that staff may be working in accordance with outdated or non-compliant procedures.

At the time of the inspection, the service was subject to organisational safeguarding measures. This meant it was working with the local authority to identify and implement improvements to the service. As a result of this an action plan was in place to address the areas identified as requiring improvement. When we requested an action plan from the manager, we found some of the actions the plan identified as being 'met' were still ongoing or not completed. For example, although the service stated that all care plans had been transferred to an electronic format, we found that not all information had been uploaded. Some key documents and details remained in paper format, leading to inconsistencies and potential gaps in the accessibility and accuracy of care records.

At the time of the inspection, the home was under monitoring and support from the local authority to ensure appropriate procedures were in place to keep people safe. Although an action plan had been implemented in response to concerns identified by the local authority in December 2025, the required improvements had not yet been achieved.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people.

Leaders lacked a clear understanding of how to implement effective improvements. Existing systems for monitoring the service were inadequate and not used effectively to support progress.

Actions were not consistently recorded where issues had been identified. For example, audits identified the oven had been broken for three months, but no actions were documented meaning there was no clear record of whether it had been repaired.

Call bell audits were not in place and there was no other system to monitor staff response to peoples requests for assistance. Failure to have effective oversight of care delivery and staff response times placed people at risk of harm and their care and support needs not being met.

There was no process in place to effectively monitor accidents and incidents, identify any trends or required learning to reduce the risk of reoccurrence. Failure to operate effective governance systems or have effective oversight placed people at increased risk of harm.

These examples demonstrate a lack of follow-up and accountability within the audit process, or the provider’s ability to ensure ongoing service improvement and compliance with regulations.