Houndswood House 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 inspection when the service was run by the previous provider, we rated this key question good. At this first assessment under the new provider 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 the governance of the service.

This service scored 25 (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 did not provide clear direction to staff about the values and behaviours expected of them or the standard of care they were to provide. People received task-based care focused on people’s physical needs such as personal care, food and drink and in some instances, this was not done well. We requested evidence of the provider’s values and how this was shared with the team but did not receive this, despite reminders.

The provider did not support leaders to have the skills, knowledge, experience and credibility to lead effectively, and to do so with integrity, openness and honesty.

The management team was not stable and comprised of newly appointed staff, inexperienced in their roles and a part time acting manager. On the first day of the site visit, the registered manager informed us they were working their notice and leaving in 3 days. The acting manager supported the service for 2 to 3 days a week with a full-time deputy manager and the clinical lead who was on site 3 days a week. Due to the high level of planned leave during the period covering the assessment, there was a shortfall of management hours, which contributed to the slow progress towards making improvements. However, the provider did not take robust action to plan ahead to ensure there were enough members of the management team consistently on duty to deliver on the required improvements. For example, during the week commencing 09 March 2025, the deputy manager was the only manager working. Due to staff absence at short notice as well as some nursing staff being unfamiliar with the service, the deputy manager had to cover nursing tasks as well as managing the service. When we visited on 10 March 2025, the deputy manager’s workload was clearly excessive, leaving them little time to address urgent improvements to provide safe care for people.

Following the site visit, the provider confirmed they had appointed a new manager who would register with CQC. They appointed to a new role of Manager’s Assistant to bolster the capacity of the management team.

Staff did not feel they could speak up and that their voice would be heard. Multiple staff told us they were not confident to raise concerns or when they did, no action was taken. Before and during this assessment, we received whistle blowing information from multiple sources who were anxious about being identified for fear of reprisals. They spoke about a culture of blame at the service where colleagues were singled out and held responsible for failings. Several staff told us about a closed culture and a reluctance from the provider to report incidents as required. In 1 instance, we were provided with documented evidence of this. These concerns reflected our experience, where we found the provider had not reported incidents and sought to minimise issues identified during the inspection. The impact of this on staff was they were fearful to report issues or felt it was futile as nothing changed. This meant where people received unsafe care, we could not be sure this would be reported and acted upon in an open and honest way.

The provider did not promote a culture of inclusion and fairness, improving equality and equity for the staff who worked for them. Although some staff told us they were happy and felt supported, others spoke about feeling tired, unsupported and feared recriminations if they raised concerns.

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.

The provider’s systems for monitoring the quality and safety of the service were not effective. Poor planning during the transition from the previous provider meant vital paperwork was no longer accessible. There were several months when no audits took place and action to address this was slow because the provider did not have oversight to identify this. They did not have a system to monitor the quality of the service at provider level and relied on the internal management team to oversee the quality of the care provided.

The widespread issues we identified during this assessment and those identified by the local authority had not been identified by the providers own governance processes. When these issues were shared with the provider, progress towards making improvements was extremely slow. The local authority and other health care professionals shared concerns that despite assurances from the provider, they saw no improvements had been made. On our second and third site visits we also found little evidence to support the assurances we had received from the provider that good progress was being made since the first site visit on 25 February 2025.

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

The provider’s understanding of what safe, high-quality care looked like was limited but they had resisted support from local groups who could offer advice on how to imbed good practice.

They had been working with external professionals including the local authority quality team for several months before our assessment but had taken insufficient action to address the significant concerns identified. Our assessment identified the same serious failings. The provider persistently minimised the seriousness of the findings, telling the local authority that CQC were happy with the progress they had made and vice versa. At the end of the assessment period there was little to no improvement made to address issues identified on the first site visit.

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. There was a lack of systems to promote continuous learning to improve the care people received. The provider's oversight was ineffective and failed to identify shortfalls found at this assessment. Where audits were completed, they had not identified trends or required improvements.