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 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 continued breach of legal regulations in relation to governance.

This service scored 25 (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.

In their continued failure to take 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 did not take place regularly and were not minuted. There were no signed attendance sheets and no record of staff having a voice in these meetings. When asked if there were attendance records, the manager confirmed the names were typed on to the sheets after the meeting had taken place.

Supervisions were completed 6 monthly and failed to identify where additional staff support was required due to limited recording around what was raised, discussed and agreed in terms of any additional support needs.

Staff spot checks were not completed regularly with most staff not having undergone a spot checks within the last 12 months. The aim of staff spot checks is to enable the provider to see if staff are delivering care safely in line with company policies.

We found the completed spot check forms did not have anywhere for the staff member to sign confirming the check had taken place or that they agreed with the information recorded. We found the provider’s spot checks lacked focus on the standard of care being delivered by staff. We also found that a spot check had been completed without the staff member being present.

This means we were not assured the documentation was a true reflection on the care being delivered by staff, at the visits documented.

Competency checks were not completed on staff. Competency checks are completed on specific tasks like administering medication, to make sure staff are carrying out the task in line with the directions on the blister pack or box.

The provider had made improvements to online staff training, but concerns were found with their face-to-face training. We found that insufficient time had been allocated for staff to complete the face-to-face training. Staff were unable to remember the face-to-face training they had completed 4 weeks earlier, with most not being able to mention more than 3 of the 9 courses completed. This indicated the training had not been delivered in a way that helped the staff to remember the information being taught.

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.

People and relatives, we spoke with, told us they had not had a review of their care plans since the care package started with the provider, and in some cases this was years earlier. This did not demonstrate a fully inclusive and collaborative process when developing their care plan and failed to identify where people’s’ needs had changed, meaning they could be putting people at risk by not delivering appropriate levels or care.

Whilst the manager told us they welcomed and supported an open-door policy for staff to speak with them about any concerns they have which staff confirmed in their feedback to us, the provider was unable to evidence this and some comments from people who raised complaints also did not reflect this was the case. Staff told us they felt confident if they reported bad practice that it would be acted on by management. Most 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 manager and provider engaged with the onsite visits, feedback on our findings and responded to our requests for information.

However, actions identified from audits the provider had completed, had not all been actioned. Where meetings or discussions with individual staff were noted as having taken place, these were not consistently recorded. There was also a lack of recording in relation to investigations noted to have been completed, as the provider was unable to provide details of these.

We found most audits were not consistently or accurately completed. The provider was unable to evidence the follow-up actions, highlighted in their audits, had been completed. This meant the oversight of the service had not improved and clear priorities for the quality and safety of people’s care was missing.

We found where the manager had delegated tasks to other office staff, they failed to ensure team members had the appropriate skills, knowledge and support to complete these tasks effectively. The provider was able to confirm who was responsible for each task, but unable to confirm what had been completed since the last assessment or how them monitored the audits being completed by the team members. Office staff did not have the required training to complete the tasks they were being assigned, this included carrying out audits, scheduling calls and writing care plans and risk assessments. These concerns were highlighted at the previous assessment also.

The manager and their delegated staff had completed most staff supervisions; however, this was not in line with company policy. Most staff had a supervision 6 monthly instead of 6 times annually, as per the policy, and the content of the supervisions was lacking detail. 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.

Most people and relatives spoke positively about the approachability of management team. However, some people and relatives also told us it was difficult contacting management at times, or that specific concerns and complaints they had raised had not always been addressed.

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

People did not 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 on the service had been gathered but it was not analysed. This meant people’s associated views and concerns were not recorded, and changes and improvements were not made. This was confirmed by some people, and relatives, who told us that they have raised concerns with the office via feedback forms, but nothing had changed following their complaints or feedback.

People and relatives told us they knew how to make a complaint. The provider had a system to manage compliments and complaints which was not consistently adhered to and demonstrated they did not respond or action concerns in a timely way.

The provider had a current whistleblowing policy. 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. This meant staff felt comfortable raising the alarm in the event of seeing something wrong.

Staff told us they could raise concerns with the 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 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 training was split between online training and face-to-face training sessions in certain topics. Our findings demonstrated the face-to-face training provided was not effective, as staff were unable to remember what training was completed, and the time taken to deliver the courses was not proportionate to what the range and nature of the important topics covered.

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 with 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 processes and systems to monitor the quality of care provided and drive improvements. However, these failed to identify 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. When asked about a concern raised by a person using the service, saying they had missed visits and left with no care for a 24- hour period, a manager suggested this was incorrect and the person “makes these things up regularly”, and “we would know if there were missed visits”. When we checked, we confirmed there were missed visits for this person on the day and found a considerable number of other potentially missed visits the provider had failed to identify, for numerous people.

We also found there was a continued lack of robust monitoring of incidents and accidents. The ineffectiveness of the governance procedures meant opportunities to drive improvement in the service to benefit people and ensure their safety had sometimes been missed.

The provider was unable to tell us which staff were using a vehicle for work, which were using public transport, and which were walking. They also failed to gather evidence where staff were driving for work purposes to demonstrate staff had valid insurance, MoT and a 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. 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, including safeguarding concerns being consistently reported to the appropriate authorities. We found that safeguarding concerns reported to the provider were not always notified to the appropriate external authorities or documented for follow-up action to be taken. This meant people were being put at increased risk of harm or abuse.

The provider did not have an effective process in place to improve service users’ support plans and risk assessments, which 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.

While the feedback given to the provider was accepted, the systems in place should have been able to identify the repeated 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.

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 sore, they [care staff] call the nurses for me.” A relative told us how they preferred to contact healthcare professionals themselves and make the care provider aware of any changes. This was due to not having confidence the provider will keep them informed.

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 assessments 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 sustained improvements in people’s care had been made since the last assessment in September 2025.

The service supported some people with a learning disability and autism. 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. RSRCRC is a framework used to regulate services supporting autistic people and people with learning disabilities. 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.