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 inadequate. 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.

There was a breach of regulation in relation to good governance.

This service scored 61 (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. They did not always understand the challenges and the needs of people and their communities.

At our last assessment, although the provider had a vision for the service, which was shared by staff, this was not apparent in the support provided to people which did not promote a positive culture. At this assessment, the manager described how they were involving staff in the changes being made at the service. They were supporting staff to be accountability for different elements of people’s support and promote the keyworker system. The manager told us this was a work in progress and there continued to be improvements needed, staff had been positive about the changes.

Staff told us, they were pleased to be given responsibility and in areas they had an interest in such as care plans or medicines. Staff told us, after our last assessment they had lost their confidence when supporting people, but the new manager had acted to rebuild their confidence.

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.

At our last assessment, the registered manager had not identified poor practice or acted to make improvements. At this assessment, though the registered manager continued to work at the service, they were no longer in day-to-day control. They had not applied to CQC, as required, to remove themself as registered manager for the service as they were no longer in this role.

The new manager had recently applied to register as the manager of the service with CQC and this was in the process of being assessed. The new manager had been registered previously at other services and understood the role of registered manager. The manager was in the process of assessing what improvements were needed in the service and updating their training such as safeguarding for managers.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.At our last assessment we found there was a culture where accountability was not always taken at a leadership level, which had a potential to foster a culture where staff did not feel able to raise concerns. At this assessment, relatives and staff told us, they felt confident to speak to and raise concerns with the new manager. Staff told us they felt supported, listened to and involved in decisions about the service.

Staff gave us examples of changes which had been made after they had raised concerns. For example, the assessment of potential residents and how this was completed. The manager told us, they would now meet with people, and a senior carer would also attend, to make sure staff could meet the person’s needs.

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.

At our last assessment, the registered manager had not always treated staff equally or addressed them by their preferred name. At this assessment, staff told us, the new manager treated them equally and involved them in the changes within the service. Staff told us, the manager had enabled them to work the shifts which suited their responsibilities outside of work, including studying. Staff had completed training in equality and diversity, which they incorporated into their role.

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.

At our last assessment, the quality assurance systems and processes had failed to identify the shortfalls at the service. At this assessment the manager had completed their own audit of the service and identified areas which needed improving. They had already started to make changes such as replacing stained mattresses. However, they did not have a comprehensive action in place to show how they were going to manage the changes and improvements they had identified.

The manager told us they wanted to support the staff to complete checks and audits which they would review to make sure they were accurate. At the time of our assessment this system was not in place and minimal audits had been completed. The provider completed regular checks during their visits. However, these had not identified the some of the shortfalls found at this assessment such the poor condition of some rooms, infection control risks and staff supervisions and there was a risk these would continue. Although the provider had taken some steps and made immediate steps to improve aspects of the issues we identified during this inspection such as signage around the home, these were reactive rather than proactive and the provider failed to identify these during its own internal governance checks.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

At our last assessment, staff had not always followed the guidance given by healthcare professionals and had not always sought guidance when people were unwell. At this assessment, improvements had been made and there was evidence staff followed the guidance given by healthcare professionals. The manager told us they had worked with healthcare professionals to promote a good relationship. Staff told us they referred people to healthcare professionals when they were unwell including mental health teams.

People maintained links with their local community and people went out with their families. There continued to be visits from the local church who spent time with people completing activities.

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

At our last assessment, there had been little improvement since our previous inspection in March 2023. At this assessment, there had been improvements including care plans, medicines and day to day management of the service. However, there were some areas including the environment and infection control where the processes the provider had in place had not identified concerns. When these concerns were identified by the new manager or during the assessment, action was taken but this was reactive not proactive. After the assessment the provider told us they were looking at ways to strengthen the processes in place.