Glenkindie Lodge Residential 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

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 good. 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.

The service was in breach of legal regulation in relation to oversight of the service.

This service scored 50 (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.

The direction of the provider did not include the quality of care, and people’s experience, as a priority. The provider had shared with us plans to incorporate this in the future.

Additionally, there was a need to embed a focus on quality assurance to work towards service improvement.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

At the time of our assessment, there were interim managers in place, which included a consultant. We were not assured that all managers and leaders were capable to complete their roles to a good standard. Additionally, staff and relatives raised concerns about managers and leaders lack of compassion and inclusivity.

We found during our time at the service, that managers and leaders were not visible. Managers and leaders were not often present in communal areas or areas used by people. This was reflected in the fact that they had not identified bad habits and practices that staff had developed and were routinely doing when providing care.

People did not always feel they could speak up and that their voice would be heard.

The provider did not actively promote the freedom to speak up initiative. Information was available for staff, people and relatives on external agencies they could contact if they had any concerns, however, there wasn’t always sufficient information such as contact details. Some people may not be able to access this information independently.

Staff told us they did not feel comfortable or confident to speak up, through fear of facing repercussions. Additionally, staff told us when they had raised concerns before, they had been ignored.

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.

Within the staff team, there were some personal relationships between staff members, managers and leaders. There was nothing in place to manage any potential conflicts of interest that may arise. This was resolved by the end of our assessment, but we were not assured that the provider had systems in place should this arise again in the future.

Some staff had declared they were living with lifelong conditions that could affect their work, however this had not been followed up, nor had an assessment of possible reasonable adjustments been completed to support staff to carry out their duties.

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.

The provider did not have robust systems and processes regarding quality assurance. Audits were not consistently completed to ensure oversight of all aspects of the service.

Additionally, we found multiple occasions the providers own policy was not being followed. For example, reporting and actioning safeguarding concerns and some aspects of medication management.

The provider had made changes to the service since taking over in February 2025. However, we were not assured that this had been sufficiently prioritised or completed in a timely manner.

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.

We found that the provider had established some links with external professionals and community organisations, however these were not always used effectively to support positive outcomes for people.

Opportunities for people to access community activities and participate in local events were limited and there was no proactive approach to developing wider community partnerships.

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.

The provider had focused its service improvement plan on aspects of the environment and employment aspects of the service. There was no focus on people’s experiences, quality of life and improving outcomes for people.

The provider shared with us their plans to incorporate this in the future, but we were not assured this had been adequately prioritised as an area of learning and improvement.