Archived: Gloucester House

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 breach of 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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

Staff did not receive regular supervisions or team meetings to ensure there was a shared vision and strategy that was understood and modelled by staff and the management team. We found no evidence that shared strategy, culture and values were embedded within the team. When responding to the warning notices, care staff told us, senior care staff were “locked in a room” and were “behind closed doors.” Care and support staff told us all they knew following the last inspection was the care plans needed to improve.

Staff had not been kept informed about the changes which were needed or involved in making improvements to improve the quality of life for those people living at Glouster House.

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, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty. The provider had not been open and transparent with staff about the improvements needed following the last assessment. The management team had not involved the staff in the work needed to improve the service.

The registered manager had not provided staff with supervision and support to develop their skills. Staff told us they did not feel supported by the provider or registered manager. Staff said that they are supported by team leaders and nurses and that information from the registered manager ‘trickles down’ to them.

Staff told us they did not always feel confident to raise concerns. Staff explained, "We want to whistle blow in our company, but other staff say it is not worth it because they know who it is." and “There is a stigma here that we just don’t raise things as it spreads instantly to the person you are raising it about.”

Another comment “We look after each other but we wouldn’t raise things to the manager. We would raise it externally as I couldn’t live with myself if I didn’t.” Another staff member told us, “We don’t raise anything as we never get updated. We asked for an update recently and was told it was being dealt with by someone else and that was it.”

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.

There was a clear policy of Equality, Diversity and Inclusion and this was evident from the staff base.

The provider did not have clear responsibilities, roles, systems of accountability and good governance.

The provider and registered manager did not have clear oversight of quality and risk in the service which contributed to people being at risk of avoidable harm. The provider had not established or operated systems to monitor and improve the safety and quality of care provision. For example, multiple audits undertaken were ineffective and had not identified the shortfalls found during our inspection, including serious shortfalls around individual risk assessments, staff understanding about the application of the Mental Capacity Act 2005.

The management team had failed to make improvements to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users. We found there had been limited identification, assessment or mitigation of individual risks. Staff did not always have guidance in how to manage people’s risks when providing their care.

The provider had a quality improvement plan; however, they had not monitored their progress against their plans to improve the quality and safety of services. They had not taken appropriate action where progress was not achieved as expected. Systems and processes to identify where quality and safety were compromised had not always been effective and did not support an immediate response when needed.

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 management team did not always promote working with health professionals and ensure people received support following guidance.

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 limited evidence the service had learnt and made improvementsfollowing the last inspection despite receiving three specific warning notices. The provider did provide extra resources, but these resources had not been effective in achieving the improvements required.

The quality of the service had not improved enough since the last inspection. The provider and registered manager had not acted to rectify shortfalls found at the previous inspection and ensuring compliance with warning notices and had not always identified concerns and issues we found during this inspection