Sandholme Fold

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 requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was in legal breach of regulations in relation to good governance.

This service scored 50 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

Improvements were needed to the workplace culture in order to ensure staff felt supported in their work. Staff were not always encouraged to be aware of the visions and values of the organisation or helped to understand how these could be used positively to deliver compassionate, person-centred care. Language and terminology used within the home was not always appropriate or respectful, indicating a culture that did not fully promote positive values. Some information shared with staff conveyed a tone which could be perceived by staff as intimidating rather than supportive.

The management team was aware of the challenges within the service when they came into post. However, there were no clearly defined expectations of the manager or deputy, or sufficient support for them to learn and understand the demands of their role when they came into post. Shortly after the inspection commenced, the manager was provided with peer support by an experienced registered manager from another of the provider’s homes. The provider told us there would be continuous presence from the regional support manager, to help develop the leadership of the home.

Opportunities to promote people’s social inclusion, connection and community involvement were limited. The service did not fully respond to the broader social impact of isolation, engagement or meaningful activity for people. The provider was working to address some of these issues by considering ways in which to improve daily activities.

Leaders did not always have the necessary skills, knowledge and experience to lead effectively.

There had been several changes to management prior to the inspection and previous leadership arrangements had been unreliable. Senior managers carrying out quality visits to the home, had not made thorough enough checks of internal quality standards and told us they 'had taken the previous manager's word for it' when they had said they did not need support. Some matters had gone unreported by the previous manager such as a skin infection outbreak, and concerns had not been detected by quality checks done by senior managers.

Provider oversight of the management of the home had not been sufficiently robust, and this lack of leadership intervention meant there were shortfalls in the quality of the care delivery.

The new home manager and deputy were recently appointed and had limited experience of running a service, although they had held team leader roles previously and were enthusiastic and committed to learn and make improvements.

The manager had been safely recruited, although their role, responsibilities and accountability had not been clearly set out. There was no evidence they had been involved in any discussions about what their role entailed and what level of support would be available for them. The provider reacted to the inspection and allocated an experienced manager from another home to work alongside the new manager. The district manager had been present in the home to offer support, but there was no clear direction for the manager to follow and limited development opportunities identified for them in their role.

The guidelines for support were not securely outlined and there was no robust programme to drive improvements and help the management team feel secure in their roles. After the inspection, the provider gave assurance that the manager would have better support in place moving forward.

Many relatives said communication with the management team was good, and they were aware of recent changes to the leadership in the home. Staff said there were marked differences in the communication since the new manager took charge and they reported increased trust and confidence.

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

Some staff told us that they had not previously felt able to speak up prior to the new manager coming into post. Speak up posters from the organisation were displayed on notice boards for staff to know how to raise concerns. However, improvements were needed around the culture in the home for staff to feel more at ease in speaking out. Written information and reminders to staff, such as in meeting minutes and supervision records, had a tone to suggest staff would be in trouble if they failed to act. This was discussed with the manager throughout inspection, and they told us they tried to be as approachable as possible and were working to build staff trust and confidence. This was evident in discussions with staff. One member of staff said, “I know I can approach [the management team] without them sending me away. I feel my feedback is listened to.”

Relatives told us issues brought up during meetings had not been resolved. There was no evidence of robust complaints recording or responses made, which meant we were not assured of a responsive or transparent process.

Relatives said they had completed questionnaires about the service but not received any feedback. During the inspection, we saw improvements made to the ‘you said, we did’ board which showed people what actions were being taken in response to their feedback.

Improvements were needed to make sure staff felt more included in the service and that their opinions were valued.

The recruitment process demonstrated a fair and equitable approach, resulting in a workforce that reflected diversity. Staff were treated fairly and equitably in the workplace, and no concerns were raised regarding discrimination or unfair treatment.

Staff told us they had increasing confidence in the way they were included and they said communication with the whole staff team was improving.

The manager told us staff were not provided with opportunities to share their views, such as through surveys, and they were considering ways in which to include staff more and encourage staff ideas and suggestions.

The governance systems and processes in place were ineffective and had not been consistently implemented. The provider oversight had been insufficient, leading to weaknesses in the quality and consistency of the service.

The manager did not have a full overview of the risks across the service which limited their ability to effectively manage and mitigate potential harm to people.

Record keeping was inconsistent, and documentation was poor or unavailable. For example, there was conflicting information in how accidents and incidents had been recorded. Staff meetings had taken place but there was no record of these prior to the inspection.

Matters identified through the assessment process had either not been identified and/or addressed through the management team’s quality checks or had been identified but without evidence of action.

Quality checks and audits were not systematic and there was no evidence of robust manager oversight or strong leadership. Where audits had been undertaken, these were not thorough or effective and lacked evidence of action taken to address identified shortfalls. For example, the provider’s audit had identified gaps in medicine PRN protocols in February 2025, yet we found this was still an issue at this assessment. There was no recorded follow up action in response to the annual water check and fire risk assessment recommendations.

The manager did not fully grasp the significance of their own role in overseeing and ensuring quality assurance. There were no systematic checks of the work done by maintenance staff, team leaders, or care staff to ensure the service ran safely and effectively.

The provider acknowledged the home had been subject to several recent management changes which had resulted in shortfalls in the governance and had unsettled the staff team. They were working hard to address the inspection findings and develop consistent processes for the safe management of the home.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not consistently focus on continuous learning, innovation and improvement across the organisation and local system.

There was limited evidence of lessons learned, such as from accidents, incidents, or falls, or analysis of these to identify trends, patterns, or ways to improve. Some investigations and root cause analyses were carried out but these were not consistently done or findings used to identify areas for improvement and share this information with staff. Reflective practice was sometimes used in response to individual situations, although this was not consistent.

At the start of the inspection, no complaints had been recorded since September 2024 and the manager said they had not received any, although further discussion showed they had received complaints via email. The manager then confirmed these had not been filed and there was no evidence of responses made. During the inspection we saw a compliant had been made in May 2025, but there was no documented response or actions shown to have been taken. This meant we had no assurance of learning from complaints to prevent similar occurrences, or evidence of the provider’s duty of candour.

The management team was responsive to feedback shared during the inspection and took steps to make immediate improvements where possible. For example, on the first day we were in the home, we raised a concern around malodours in particular rooms, as well as a data protection concern, as sensitive documents with vast amounts of confidential information were accessible in the entrance in a lockable but unlocked cabinet. By day 2 the cabinet had been moved to a secure area and the malodours had been addressed. Assurances were given by the provider in response to all of the discussions held after each site visit, to show their ongoing and intended improvements. The provider was taking some steps to put consistent support in place for the development of the management team, to help establish and embed more thorough checks of quality and safety.