Archived: Glenholme

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 good governance. There was a lack of systems to assess the quality of care that people received and minimal policies and procedures in place.

This service scored 32 (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. The provider could not evidence to us a mission statement that recorded their aims and values expected. They did not have an up-to-date statement of purpose which is a legal document that outlines the key details of the care service they are providing. There were no meeting minutes and no improvement plans. There were a limited number of audits being conducted and those in place were not completed accurately. We found a lack of transparency within the service and it was a closed culture.

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. The provider and registered manager did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty. We found concerns in recruitment records and a lack of staff support and oversight and no discussions around ongoing development. There was no duty of candour processes in place and no spot checks about the quality of care people received. When we spoke to the registered manager about their skills and experience, they said, “I do not have any training, I do not have any time. Online training I have not done for years.” During our assessment the registered manager resigned and the provider recruited a new manager.

People did not feel they could speak up and that their voice would be heard. We found concerns throughout our assessment that people were not actively encouraged to speak up. No staff had spoken up previously. The service had a whistleblowing policy although the contact information within the policy was inaccurate. There was no evidence of complaints on file and no investigations conducted. We found several concerns throughout our assessment on the culture in which staff talked to people in the service by reviewing their care notes. No staff raised these records as a concern and no investigations were conducted.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. There was no evidence of any processes to support staff wellbeing at the service. There was no evidence of staff being spoken to on a regular basis. However, speaking to one staff member they expressed how they were supported with a flexible working request. Staff appeared to be treated with equality, diversity and inclusion

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. We found systematic and extensive failings in the service and the management of it. The provider failed to ensure that there were safe and effective systems in place to be assured that people were protected from harm and received good care. Audits were minimal and did not cover visual areas within the service. They were completed inaccurately and there was no oversight around this. If actions were identified there was no process to monitor this and the provider could not be assured what was required and was completed. Systems that were in place were not embedded and there was no clear process for staff to follow. The service had minimal policies and procedures in place. Staff did what they felt was suitable and as such did not always meet people’s care needs.

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 service could not evidence that referrals were being submitted and escalated when needed. They could not evidence communication with local forums or groups. However, most people in the service went out on a regular basis with some people doing some local volunteering at the local church.

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. We found training records were poor and there was no evidence of what was reviewed in the policies and procedures on site. We found on the local authority’s provider assessed and market management solution (PAMMS) inspection that they had given the provider an action plan with areas of improvement that were identified, and the service had signed actions off that had not been completed. The service could not evidence improvement from learning or feedback that they had received.