Arliemoor 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 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 requirements where the service provider is an individual or a partnership, notification of incidents, absence, changes and good governance.

This service scored 39 (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’s shared vision for the service was to provide a safe environment where people were valued and supported to develop a sense of self‑worth and independence. Staff demonstrated an understanding of the provider’s aims and objectives. However, since the provider stepped back from the day‑to‑day management of the service, there had been a lack of clear leadership, direction, and oversight. As a result, the culture of the service no longer consistently reflected these values or promoted good outcomes for people.

There was a limited understanding across the service of how to meet regulatory requirements and deliver high‑quality care and support to people with mental ill health. This was evident throughout the inspection and reflected in the culture established by the provider, where people were not consistently valued, empowered, or supported to achieve positive outcomes. Furthermore, the provider was unable to recognise the extent to which the culture within the service had deteriorated or understand how this was affecting people’s day‑to‑day experiences.

Managers told us they promoted an open and honest culture in which information was shared with staff. However, we found that effective systems and processes were not in place to ensure staff were adequately supported or equipped with the skills and knowledge required to maintain a positive, inclusive, and safe culture within the service.Although staff described a generally supportive working environment where their contributions were recognised and valued by managers, they were not empowered to effect positive change. Managers and staff told us they were unable to implement improvements or influence the direction of the service, as decision‑making remained with the provider. This limited the service’s ability to embed learning, drive improvement, and demonstrated ineffective leadership and governance. This contributed to a breach of regulation relating to good governance.

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, or experience to lead effectively.

The registered provider and managers did not demonstrate sufficient oversight of the service to ensure people received care and support that promoted their wellbeing and protected them from harm. They did not identify the concerns we found at this assessment or have a plan in place to address those concerns.

There was a lack of understanding of how to meet regulatory requirements and deliver high‑quality care and support for people living with mental ill health. This reflected a failure to establish and operate effective systems and processes for good governance.

As a result, the service demonstrated a poor culture characterised by low expectations and a lack of purposefulness in people’s day‑to‑day lives. Insufficient oversight and leadership meant that people were not consistently treated with dignity and respect, and there was a lack of assurance that care delivery was monitored, reviewed, or improved.

Poor decision‑making and judgments placed people at potential risk of harm. This included failures in staff recruitment, risk management, and safeguarding people from abuse, as well as a failure to implement, embed, and follow the provider’s own policies and procedures.

The provider did not engage with the inspection process and was unable to answer questions relating to the day‑to‑day running of the service. During discussions, the provider confirmed that they were no longer in day‑to‑day charge of the service, were unsure of their regulatory responsibilities, and stated they did not wish to continue running the service. However, as the registered provider, they remain legally responsible for ensuring the service is managed safely and effectively and complies with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The failure to maintain the necessary skills, knowledge, competence or availability required to carry on the regulated activity or oversee its management effectively contributed to a breach of regulation in relation to requirements where the service provider is an individual or a partnership and good governance.

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

The provider had policies in place to support staff to speak up, raise concerns, and keep people safe. People told us they were aware of how to make a complaint and said they would raise concerns directly with the manager if something was not right. One person said, “I would tell [manager’s name].”

Staff spoke positively about the managers and described a supportive working environment where they felt listened to and valued. Comments included: “100%, I do feel supported by [managers’ names]. We chat as a group and I am happy here” “Yeah, absolutely, I would say I feel supported by [managers’ names], no concerns around that at all” and “Seriously, [managers’ names] are very supportive and approachable.”

However, although staff felt personally supported, they were not empowered to effect positive change within the service. Managers and staff told us they were unable to implement improvements or influence the direction of the service, as decision‑making remained with the provider. One staff member said, “Improvements need to be made in the way it is run. That will change when the provider moves out. We will be able to make positive changes once that happens, and it will be more about the people and less about it being the provider’s house.”

This limited the service’s ability to embed learning, drive improvement, and demonstrated ineffective leadership and governance. This contributed to a breach of regulation relating to good governance.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Most staff had worked for the provider for many years. The service promoted an open, transparent, and inclusive culture in which staff felt welcomed and accepted. Managers told us the service did not tolerate bullying, harassment, or discrimination and demonstrated an understanding of their legal responsibilities under the Equality Act 2010, including the duty to make reasonable adjustments for staff, and described how they would tailor employment arrangements to meet a staff member’s specific needs.

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.

At the time of the inspection, the registered provider told us they were no longer in day‑to‑day control of the service and were unable to manage it in line with their legal responsibilities. The service was being managed by two managers. Staff consistently told us that the provider had not been responsible for the day‑to‑day running of the service for several years. This was a breach of regulation in relation to requirements where the service provider is an individual or a partnership.

Managers told us they were unable to locate essential documentation, including service user assessments, staff recruitment records, and governance information. They also reported that they could not access the funds required to meet day‑to‑day running costs, make operational decisions, or drive effective change within the service.

We found there were no clear lines of responsibility or accountability within the management structure. It was unclear how decisions were made or who was actually responsible and accountable for the management of the service. Although the provider was not in day‑to‑day charge of the service, they continued to make decisions relating to its operation. Managers told us they were struggling to cope with the current situation and appeared visibly overwhelmed. The absence of effective leadership, oversight, and access to necessary resources meant that managers were unable to safely and effectively manage the service. This resulted in significant risks to the quality and safety of care being provided.

Governance arrangements were absent. The provider had not developed or implemented governance systems capable of assessing, monitoring, or improving the health, safety, and welfare of service users or effectively driving improvements. As a result, they did not identify or have a plan in place to address the widespread and systemic serious failings in relation to the safety, quality and standard of the service or maintain compliance with regulatory requirements. This contributed to a breach of regulations relating to requirements where the service provider is an individual or a partnership, and good governance.

Neither the provider nor the managers fully understood their responsibilities under the Duty of Candour, which requires providers to be open and honest about any accident or incident that has caused, or placed a person at risk of harm. As a result, the provider failed to notify the Care Quality Commission (CQC) of four significant events in line with their legal responsibilities and also failed to formally notify the CQC that they were no longer in day‑to‑day charge of the service. This contributed to a breach of regulation in relation to notifying CQC of significant events, absence and planned changes in line with their legal responsibilities, requirements where the service provider is an individual or a partnership, and good governance.

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

Managers recognised the importance of working in partnership to improve people’s outcomes. They described how they worked collaboratively with people, their families where appropriate, and the local authority to support positive outcomes. Records showed that staff engaged with healthcare professionals, including GPs and Community Mental Health Teams, as required.

However, we found that staff did not always raise concerns or make referrals promptly. We discussed this with managers, who told us there were times when they felt unsupported by external agencies, as they were slow to engage or offer support.

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 provider did not demonstrate a culture of learning or continuous improvement. A lack of effective oversight and robust governance arrangements meant that widespread and systemic failings relating to the safety, quality, and standard of care were not identified, assessed, or addressed. For example, the provider failed to ensure that the premises were clean, suitable for their intended purpose, and properly maintained. There was limited assurance that staff had the necessary skills, knowledge, and experience to meet people’s needs safely. Lessons were not learned following incidents. In addition, the provider was also unable to recognise that the culture within the service had deteriorated and did not recognise the impact this was having on people’s quality of life and the staff team. This contributed to a breach of regulations relating to requirements where the service provider is an individual or a partnership, and good governance.

Throughout the assessment, the registered provider and managers were open and honest, acknowledging the areas requiring improvement.