Archived: Kettlewell House Nursing 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 good. 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.
 

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.
We reviewed staff meeting minutes and found staff expressed concern regarding the high turnover of management, and the impact of this around care delivery and implementing new systems and processes. Some people and relatives told us they were not aware of the new interim manager.
We also reviewed investigation reports with staff following allegations of abuse within the home. Staff comments demonstrated a lack of transparency, closed culture, and concerns around the human rights. For example, one staff said, “I believe it is always happening…they are always abusing [people].” Another staff said, “All the staff know of this going on.”
The provider failed to evidence these concerns were all addressed, investigated and actioned without delay. This meant people were at ongoing risk of harm and abuse.
 

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 service had 5 managers since July 2024. An interim manager was in place at the time of the site visit. The inconsistency and lack of continuity in strong leadership and management meant there was impact to care delivery. During the inspection we found the interim manager lacked knowledge of people’s needs, for example how many people required support with eating. The interim manager also lacked access to information such as previous complaints and files. Staff and people told us of the negative impact experienced from constant management changes in the service.
The inconsistent leadership and lack of oversight of care quality meant there were significant ongoing risks to safe service delivery. Staff told us they felt pressure from not having a permanent manager, and as each manager had their own priorities, the frequent high turnover was difficult. One staff said, “Staff were encouraged to speak up but then a manager changed, and no actions taken forward; new managers wanted to ‘make improvements’ and this meant the approach/method of doing things kept changing.”
Relatives also told us, “The staff have a good relationship with each other and the [people] but the change in management has affected them.”
 

People did not feel they could speak up and that their voice would be heard.
We saw some posters with information about whistleblowing were displayed around the service. However, one staff we spoke with told us they had been bullied when they had raised concerns. This did not demonstrate the culture was encouraging to speak up, and people were supported through all alternative means of speaking up. We reviewed staff statements and found unsafe practices and abuse risks remained hidden, which exposed people to harm. One staff said, “Here we tend to normalise things, and we have started transferring people without warning them, or putting on the foot plates without communicating.” We also found some staff suggested safeguarding concerns would still not be raised by staff despite being aware of the risks, harm and abuse to people in the service. This demonstrated a closed culture and a weak whistleblowing process in place, whereby systems and culture did not empower or encourage speaking up.
 

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.
The manager told us the service was diverse, and “There might be some small language barriers we can accommodate. There is always a translator to deliver the message. I don’t tolerate discrimination.”
 

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 failed to present requested documentation and assurances without delay, including assurances around people’s safety, safeguarding, incidents, allegations of abuse and ongoing risk to people within the service.
Despite concerns raised with the provider throughout the site visit and feedback, the provider did not feel there were ‘serious concerns’ identified. The provider failed to provide any assurance the concerns and evidence we shared were immediately taken onboard and the provider understood the seriousness of the concerns.
The provider failed to operate robust and effective systems to safeguard people from abuse, prevent a closed culture where unsafe care was normalised, investigate and act on allegations of abuse without delay, and work transparently with safeguarding partnership agencies.
We found the provider’s audits were ineffective and lacked robust quality assurance to identify and address concerns within the service. For example, the medicines audit showed 100% compliance despite multiple unsafe practices identified by inspectors. This meant the leadership team were falsely assured of safety, and risks to people were not acted upon.
The provider failed to implement a clear and robust policy and process to ensure safe recruitment of staff. The provider failed to establish and maintain a strong leadership within the service to ensure continuity in care delivery, effective oversight and governance. One staff told us, “I think we have had lots of new managers. We try to get to know them then they leave. New manager who comes will not know staff well; staff don’t get used to managers. Get fed up telling each manager same things.”
 

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.
We found the provider failed to evidence all safeguarding concerns were shared with the appropriate partnership agencies without delay. This meant there was a lack of transparency and proactivity to ensure people were not exposed to ongoing risk of harm and abuse.
We requested information from the provider, including evidence of duty of candour, learning outcomes and investigation reports. These requests were not always responded to. The provider did not demonstrate they understood their duty to work collaboratively to ensure people were safely supported. This also meant the provider did not demonstrate an understanding of their regulatory responsibilities.
 

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 a lack of oversight, failure to identify themes, and a failure to reduce recurrence of harm. The impact of this meant there was ongoing risk abuse continued undetected and unchallenged, increasing cumulative harm.
Relatives felt the service failed to promote an environment which empowered and promoted speaking up. One relative told us, “The home group blamed the carers for not saying anything but if there isn’t an environment that’s conducive to whistleblowing, they won’t.”