Archived: Clubworthy House

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 regulation in relation to 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 provider did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The provider’s stated ethos and vision for the service did not match the reality of the care people experienced. The providers had failed to identify the inherent risk factors which made the service vulnerable to a closed culture developing. The providers lived at the service, and there was a small team providing support. People were unable to leave of their own accord and had limited access to community facilities and groups due to the rural location of the service.

During this assessment, we heard multiple allegations that the provider had, at times, excluded, belittled and taunted people and took a punitive approach to care. We heard that staff were not encouraged to raise concerns and felt a need to be complicit with the provider’s approach, in part because at times the providers were generous and treated staff well. One staff member told us, “Their ethos sounds so good at interview, but really it’s an ethos of control and coercion”. The impact of this meant the atmosphere was unpredictable and inconsistent. Another staff member said, “It’s a horrendous atmosphere, you don’t know what you’re walking into. Some days they will be sweetness and light, other days a nightmare. It’s all about control”. This impacted on people living at the service and their ability to make real choices about how to spend their time; a third staff member said, “I’ve rarely heard [people] refuse [to do the planned activity]”.

We found that the culture of the service did not always put people living at the service at the centre of decision making. The providers told us they viewed themselves as living in the care home and it being people’s home first and foremost. However, we found the communal living arrangements introduced difficulties which impacted on people living at the service. For example, one staff member told us, “They will say it’s a care home, but will also say this is our house, you’re not just doing things willy nilly in our house”. We heard multiple accounts of the provider telling people to “[expletive] off out of my kitchen”. Another staff member said, “They [providers] argue, [name] tells [name] to shut up all the time”. There was no division between the provider’s personal and professional life, and in effect the care home ran like a family home, with meals and household chores shared between the providers, staff, and people living at the service. This approach had some positive outcomes for people but was not in line with best practice and also exposed people to harm.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Staff consistently told us the providers lacked the leadership skills required to operate the service in line with best practice including Right support, right care, right culture. The culture at the service meant it was not inclusive, and the provider did not always work openly and in line with their own policies. The providers were not aware of their own limitations and did not access support or independent scrutiny. They failed to identify or act on signs of a closed culture which affected the quality of people’s care and had a detrimental impact on staff.

People did not feel they could speak up and that their voice would be heard.

One person told us they had spoken up about being unhappy at the service, both to the provider and to health professionals. They, and staff, told us their concerns were not taken seriously, and they were accused of being dishonest. We shared our concerns with the Local Authority, and one person was moved from the service within 24 hours of our inspection.

The provider told us they encouraged staff to speak up. They had policies and appropriate phone numbers for staff to report concerns were displayed in the office. However, staff told us when they raised concerns, they were not listened too. One staff member said, “I’ve tried raising it, but they just argue”. I have to go and unwind and talk to other staff, it makes you feel crazy, it’s like a toxic relationship”. Another staff member said, “I didn’t raise my concerns with them, there’s no point as they always have to be right, they will try and flatten you with legislation, they have an answer for everything”.

Where staff had raised concerns to partner agencies in the past, we saw the provider had made counter allegations about the staff member’s conduct which discredited their account. Staff meeting minutes recorded this information being shared with the current staff team, including informing them it may affect the ex-staff member’s ability to work in the future. This discouraged staff from speaking up.

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.

The provider failed to continuously review and improve the culture of the organisation in the context of equality, diversity and inclusion.

Staff did not feel they were treated fairly and did not think people’s human rights were always upheld. Staff told us of the emotional impact of working at the service, including having “sleepless nights”. One staff member said, “You feel awful, because you get dragged into it”.

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

Governance systems failed to identify poor practice and that people were not receiving care in line with Right support, right care, right culture. There were no systems of accountability or oversight, and whilst the providers closely monitored and assessed the actions, behaviour and performance of staff, they did not apply the same scrutiny to their own conduct when delivering care.

The service was a family run organisation and there were no senior positions held by non-family members. The providers had not considered the inherent difficulties in this arrangement. For example, how staff might be supported to raise safeguarding concerns which involved the providers.

Systems were in place to routinely audit and analyse records, including records relating to medicines, care plans and risk assessments.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider did not always work or share information openly where concerns were raised, however, they did work well with partners and other healthcare organisations when supporting people with their physical health needs. They had some connections with community groups and invited members of the local community to events held at the home.

We received positive feedback from some members of the local community. They told us people appeared to be well supported and treated with dignity and respect at the times they saw them.

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. They did not actively contribute to safe, effective practice and research.

The providers did not demonstrate an improvement culture and did not have systems to measure outcomes or impact on people. There was limited learning from things that had gone wrong, a lack of reflection or collective problem solving and examples of good practice were not used to develop the service.