Archived: Living Glory Social Care

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 inadequate. At this assessment the rating has remained inadequate. This meant there were both widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service remained in breach of 1 legal regulation in relation to good 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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not clearly understand the challenges and the needs of people and their communities.

In their failure to continue taking consistent and timely action in response to risks and concerns, the provider had not prioritised safe and high-quality care or the promotion of a culture focused on learning and improvement.

Staff meetings, supervisions and spot checks had been improved since the last assessment and identified where additional staff support was required. However, these had not been completed for all staff and followed up once additional support or learning was required. For some staff we spoke with we continued to find their ability to tell us about their learning from training was limited due to language barriers or a lack of knowledge and understanding. This meant we could not be assured the current training met the needs of all staff.

Reviews of people’s care plans did not demonstrate a fully inclusive and collaborative process when developing their care plan.

The provider had made improvements to staff training; however, this still fell short in reflecting people’s individual needs and to further promote equality and diversity. We continued to find risk assessment and care planning processes did not fully reflect and acknowledge people’s diverse needs and continued to require further development.

Whilst the registered manager told us they welcomed and supported an open culture which staff confirmed in their feedback to us, some comments from people who raised complaints did not reflect this was the case. Most staff had received training in recognising closed cultures and told us what they would do if they witnessed poor practice. They said they were confident if they reported this, that it would be acted on by management. People and relatives told us overall staff were kind and compassionate.

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.

During our assessment the registered manager and provider engaged with the onsite visits, feedback on our findings and responded to our requests for information. The registered manager and provider were receptive, overall, to our feedback and took some steps to immediately improve shortfalls which we identified during the assessment.

Actions identified from audits the provider had completed were not added to their action plan. We found some required actions affecting the safety of people continued to not always be completed in a timely way.

Since the last assessment the provider had implemented a number of audits. However, we found many of these to be ineffective in identifying where actions were required or ensuring actions were completed. This meant although the oversight of the service had improved, shortfalls and priorities for the quality and safety of people’s care had not improved enough. We found where the registered manager had delegated tasks to other office staff, they failed to ensure that team members had the appropriate skills, knowledge and support to manage the service effectively. For example, the provider had little oversight of staff who were carrying out audits, scheduling calls and writing care plans and risk assessments, this contributed to the on-going shortfalls in the service.

The registered manager and their delegated staff had completed supervisions with staff, although some staff had been missed. Some staff had not received any supervisions at all for the period of January to September 2025. Those supervisions which had been completed included discussions with staff around training to carry out their roles and provided the opportunity for staff to identify additional support or development needs they may have. However, supervisions for staff supporting people with a learning disability or autistic people along with those involved in medicines administration, did not demonstrate that staff’s associated competencies were assessed.

People and their relatives told us they knew who the registered manager was; however, it was not always clear who they were referring to, as they sometimes spoke of a male manager.

People and relatives spoke positively overall about the management team and told us they were approachable.

Staff told us they felt supported and valued by the management team and understood their roles and responsibilities.

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

The provider’s approach in gathering feedback from people to give them the opportunity to share any concerns they may have was not fully inclusive.

We saw feedback had been gathered and analysed; however, some people or their relatives told us nothing had changed following their feedback.

People and relatives told us they knew how to make a complaint. The provider had a system to manage compliments and complaints which demonstrated they had been actioned in a timely way.

The provider had a current whistleblowing policy. There had been improvements since our last assessment and there was a process to follow if staff or people spoke up and that their voice would be heard.

Most staff had received training and could tell us what whistleblowing meant. They also knew how to escalate concerns should the registered manager or provider not take any actions.

Staff told us they could raise concerns with the registered manager at any time and felt they would be listened to and actions taken.

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.

Although records demonstrated staff received training, we found this training was not adequate to ensure they had the appropriate skills to safely fulfil their roles and meet all people’s known support requirements and needs.

We saw most staff had received equality and diversity training to improve their awareness of these principles. However, the provider had failed to implement a robust process to assess staff knowledge and skills following this learning and how they applied this in the service. The registered manager told us if staff required additional support with learning, they would facilitate this. However, we found there were some shortfalls in staff members’ ability to describe their learning and understanding of certain key topics. We saw and were told there had been some consideration and adjustments made to how staff training was delivered, which was mostly on-line but also now included some face-to-face sessions in certain topics. Our findings demonstrated improvements made to staff training still required time to be embedded and demonstrate they were effective.

There were no systems in place for matching staff to people, for example, if a person spoke a particular language. The staff allocation was based more on location of the person’s home address and staff who were available in that given area rather than to suit a person’s individual needs and preferences in relation to language and communication.

Staff told us overall they were happy working for the provider, and many staff had been in the service for several years.

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 had implemented new processes and systems to monitor the quality of care provided and drive improvements since our last assessment. However, as many of these had not identified the concerns we found in the service, and so we could not be assured these were effective. For example, we found inaccurate and unclear information in some people's care and risk management plans. There was poor guidance for staff on, and oversight of, medicines management, and a lack of effective monitoring of short, late and missed calls. Records relating to the use of restraint were not sufficiently clear and detailed or in line with national guidance. We also found there was a continued lack of robust monitoring of incidents and accidents. The ineffectiveness of your governance procedures meant opportunities to drive improvement in the service to benefit people and ensure their safety had sometimes been missed.

We saw the provider had implemented a selection of environmental risk assessments and had a new suite of policies and procedures since we last assessed the service. However, we found in many areas the provider failed to fully adhere to their own policies. This meant their actions were not always fully reflective of current legislation.

The provider did not complete comprehensive staff recruitment checks which was unsafe. This included exploring gaps in employment and obtaining suitable references. Staff who had known health conditions or were pregnant did not have risk assessments to ensure adequate measures were in place to ensure both the staff members’ and service users’ safety. They also failed to gather evidence where staff were driving for work purposes to demonstrate staff had valid insurance, MoT and driving licence to safely and legally undertake this task.

The effectiveness of staff training was not assessed, and there was a lack of checks to demonstrate staff were competent to carry out their roles. This was a recurring concern which was identified at our last assessment. The lack of oversight by the provider meant they could not assure themselves that staff were skilled and had the necessary knowledge to undertake their job roles safely.

The provider failed to ensure that safeguarding processes to identify when people were at risk of abuse were effective. Where incidents happened, the correct actions were not always taken or reported to the appropriate authorities. During this inspection we raised several safeguarding alerts to the local safeguarding team as we found people were at risk from abuse.

Whilst the provider had started to improve service users’ support plans and risk assessments, they were not formally or effectively audited, as demonstrated by the discrepancies and missing information we found. This meant people were placed at risk as the provider's systems failed to provide staff members with robust information to keep people safe.

The provider had not considered how the service would continue to operate in the event of staffing levels being affected by changes to overseas working arrangements. This meant we could not be assured that people’s calls would still be fulfilled and their care needs met.

Whilst we recognise the provider was receptive and responsive to our findings during this assessment, the systems in place should have been comprehensive enough to identify the shortfalls in the service and enable them to make the necessary improvements.

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 involvement of healthcare professionals such as district nurses was not always recorded in people’s care records. Neither was it clear how the provider engaged with others, so people could remain safe and independent.

Staff told us they could make referrals to health and social care professionals via the management team. Relatives we spoke with and the provider confirmed relevant health and social care professionals were involved with people’s care. One person told us, “If I am unwell, they [care staff] will call and ambulance.” A relative told us how they chose to liaise with health professionals for their loved ones but kept the staff up to date with any changes to the plan of care.

During the assessment we contacted the commissioning authorities and health professionals involved in peoples care and support. Whilst not all responded, the feedback we received was used to help focus on areas where improvement had been identified.

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.

Lessons learnt from previous inspections was not evident and further shortfalls in the quality and safety of people’s care were found at this assessment. We continued to find significant concerns in the safety and quality of people’s care, a number of which represent repeated failings. The lack of effective systems and processes for assessing and monitoring the safety and quality of people’s care led to the to the failings in the service. Our assessment identified continued breaches of good governance, person-centred care, gaining consent, safe care, safeguarding people from abuse, staffing and fit and proper persons employed.

The provider was not able to demonstrate improvements in people’s care had been made since the last assessment.

The service supported some people with a learning disability and autism and although they told us they were aware of current best practice guidance including Right support, right care, right culture, they were unable to demonstrate how they had put this into practice. Care records needed significant development to better reflect this guidance and to demonstrate how they were enabling people to promote their independence, identify pathways to future goals and enjoy a full life.