Sholden Hall Residential 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 Requires Improvement. 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 continued breach of the legal regulation in relation to governance at the service.

This service scored 36 (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 had a shared vision, strategy and culture. The provider told us they were passionate about people’s experience of care and wanted this to be high-quality. Staff shared this same vision and expressed positive values. People and relatives were positive about the staff and management. A person said, “The staff are very nice, always willing to help you.” A relative said, “[Registered manager] phones if there’s anything to discuss and we talk about it…They’re very open here.”

However, the practices within the service did not always support the vision and demonstrate a positive culture. The vision, strategy and culture was not always based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. During the inspection the communication between the registered manager and staff was not always positive. The registered manager did not always take accountability for the practices within the service and told staff they should know correct and good practices for example around diabetes management.

During the inspection we were not always assured that the registered manager was being transparent when asked about incidents. We asked about incidents that had taken place and the registered manager told us certain incidents had not occurred. These incidents however had been documented by the registered manager on their system such as restraint practices. The management and staff did not always demonstrate clear understanding of how to meet people’s needs and how to manage challenges around these. People had not always experienced safe, comprehensive and timely care to meet their needs holistically as a result.

Following the inspection the provider told us they were making improvement to communication within the service.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the necessary skills, knowledge, experience and credibility to lead effectively, and they did not always do so with integrity, openness and honesty.

The leadership and management at the service was not robust despite the provider regularly supporting the management team. For example, people’s risks were not always effectively managed. People had experienced poor care that infringed on their rights which the leadership team had not been alert to nor had swift action been taken to address these issues. The leadership at the service had not been aware of all of the issues that we found at this inspection for example infection control issues had not been identified as governance processes were not robustly completed. At this inspection we found actions were still outstanding from the last inspection which had not been resolved by the management team such as ensuring the governance systems and processes were robust and effective. Following the inspection the provider told us they were making some changes to the leadership of the service.

The provider had not always fostered a positive culture where people spoke up. Staff told us they felt able to raise concerns to the management team. However, staff were not always knowledgeable about potential safeguarding concerns and restrictive practices which meant concerns had not always been appropriately escalated.

During our inspection we observed a culture where accountability was not always taken at a leadership level which had potential to foster a culture where people did not feel able to share concerns as reported on under the shared direction and culture quality statement.

Despite the concerns we found during our inspection some people and relatives told us they had no cause to complain and felt staff would listen if they did. Other people gave examples of issues they had raised with the management team and told us they had been resolved to their satisfaction.

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. However, the registered manager had not always demonstrated these same values. The registered manager did not always address staff by their preferred names and communication between the registered manager and staff required improvement.

Staff were positive about their experiences of working at the service. They told us reasonable adjustments were made for them when required and told us they were treated fairly. Staff had completed training in equality and diversity; they were mindful about applying their knowledge to benefit people they supported.

The provider had not established clear responsibilities, roles, systems of accountability and good governance. They continued not to act on the best information about risk, performance and outcomes. The provider continued to not have robust and effective governance systems in place.

Quality assurance systems and processes were routinely carried out across all areas of service delivery but had failed to identify some of the issues we found at this inspection. The processes in place did not identify the issues with risk mitigation for people’s individual risks we found at this inspection. They also failed to identify issues with the safe management of medicines, fire safety, infection control and safe recruitment practices reported on under the safe key question.

Systems to ensure people’s care plans were up-to-date and accurate had failed to effectively meet their aim. For example, some people’s records lacked detail and consistent guidance, staff did not have the information they needed to support people safely.

Audits had failed to identify where people’s care was not being delivered as planned such as diabetes management, close monitoring of particular people and engagement in activities to promote well-being.

The quality assurance systems and processes did not identify concerns with the care practices taking place in the service such as unplanned restraints that had occurred. This meant the provider did not take timely action to ensure any restraint that took place was safe and proportionate.

One instance where a person had absconded from the service was also not highlighted during the quality assurance processes. Because the governance processes within the service were not being applied robustly and effectively, the provider did not identify that they had not notified the Care Quality Commission in line with their legal requirement to do so for this incident. We requested them to submit a notification retrospectively, which they did following the inspection.

Where the quality assurance systems did identify issues with practice at the service such as record keeping of care entries not always being accurate, complete or contemporaneous. Mechanisms to address this and drive improvement had not been effectively implemented, and we found these identified issues were still in place at the time of our inspection.

Some areas for improvement at the last inspection still remained at this inspection such as concerns around diabetes management and governance of the service. The provider’s systems and processes had not been used effectively to ensure people received safe, effective and high-quality care.

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 leadership team were keen to work in partnership with relevant professionals and partner agencies. Healthcare professionals confirmed they received referrals from the service in relation to people’s health needs. A relative told us, “The District Nurses are really good and get on well with all the staff.”

However, partnership working was not always carried out robustly. Staff had not always followed healthcare professionals advice on managing health conditions such as diabetes. Staff and the leadership team had not always sought advice from all relevant professionals or agencies to manage people’s needs holistically.

Staff told us they worked well with other professionals to meet people’s needs such as GP’s, District Nurses and Mental Health teams.

People were able to maintain some links with their local community. For example, visits from leaders of faith who came to the home and outside entertainers were invited in as part of the activities programme.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage delivery of equality of experience, outcome and quality of life for people. They did not actively contribute to safe and effective practice.

At the beginning of our inspection the registered manager told us, “From last inspection [there has been] vast improvement. The staff are doing their job.” However, we found the provider had continued to have issues with the oversight and management of the care delivered. Some issues remained since the last inspection and the providers action plan had failed to drive sufficient improvement in these areas. The provider has been in breach of legal regulations in relation to safe care and treatment and good governance for the last 2 consecutive assessments and therefore we were not assured the systems and processes in place were robust to identify learning and drive improvement. The provider took some action to address concerns we raised during our inspection however actions taken were not robust to fully address concerns raised. For example, we fed back that professional advice around blood glucose level monitoring was not being followed in practice. The leadership team told us they had addressed it when we returned for a second day to the home. However, midday blood glucose levels had continued to not be recorded. We fed back concerns about risk management where there had been incidents of restraint which had not been lawful and staff had not been trained, the provider focused on staff training and not learning and improvement from the incidents as a whole.