Glebe House

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 relating to governance at the service.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not foster a positive culture and environment for people and the providers values were not always upheld by the staff team.There was insufficient evidence to demonstrate that the provider had established, communicated, or embedded a clear and coherent vision for delivering high-quality, person-centred care.

Although the provider had developed relevant policies intended to support high-quality, person-centred care, these were not consistently implemented. Feedback from staff indicated a disconnect between policy and frontline delivery, suggesting that staff either lacked an understanding of the policies or did not receive adequate support to apply them effectively. A staff member told us “I feel there is a lack of leadership and oversight within the service, and it would be helpful if we were all followed policy.”

Staff reported that morale within the team was low, with noticeable divisions among staff members. This fragmentation contributed to a disconnect between the leadership team and the wider workforce. Furthermore, there was limited evidence to suggest that leaders actively engaged with people using the service or made meaningful efforts to understand and respond to their lived experiences.

For example, there was no guidance in place for staff to follow to help support a person who would often become anxious about how they received their care and support and how staff should respond to them. This lack of guidance meant that staff may not have clear instructions on best practices to follow when supporting someone who frequently becomes anxious about their care, potentially leading to inconsistent or inadequate support.

Following discussions with the registered manager, evidence was provided demonstrating that active measures have been implemented to improve the team culture. These measures include training sessions and workshops to foster a more positive and collaborative working environment. In addition, the registered manager has put in place specific guidance for staff to help manage a person’s anxiety.

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.

During the assessment, we identified that the registered manager did not fully understand their responsibilities as a registered person. This was evidenced by several and significant shortfalls identified in the areas of care and support provided to people using the service. These shortcomings raised concerns regarding the safety and effectiveness of the care delivered placing people at risk of harm.

The concerns included, inadequate risk assessments and failure to implement appropriate risk management plans for individuals, potentially exposing them to avoidable harm. Gaps in care planning, with care plans not being regularly reviewed or updated to reflect individuals’ changing needs and preferences and failure to monitor and evaluate the quality of care, which meant issues were not identified or addressed in a timely manner.

We saw that regular staff meetings were taking place. These meetings provided a crucial forum for staff to communicate and collaborate effectively, sharing their ideas to contribute to service improvements. For example, after our visit we saw that the registered manager held a meeting with staff to discuss the some of our findings and changes that were required.

There was mixed feedback from the staff team regarding how the registeredmanager managed the home. Some staff felt they were supported however, others felt that the registered manager lacked support and direction and was not in the home long enough to provide support.

The provider sent us further evidence after our inspection, which included up to date risk assessment, care plans and guidance for staff to follow. However, due to this information not being available to staff during our inspection this was a potential risk to people receiving safe care and support

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

During the assessment, a person said, “There is no point in saying anything as nothing changes. I’m just told we will look into it, but the staff never come back to me.”

Staff demonstrated a clear understanding of the whistleblowing policy and were aware of their roles and responsibilities in reporting concerns. However, Not all staff felt confident that their concerns would be heard or acted upon. Although policies existed to promote openness and transparency, some staff expressed concerns about the potential for unfair treatment if they raised issues or spoke out. This suggested that the intended culture was not fully embedded, and that staff did not consistently feel safe or supported to voice concerns. A staff member told us, “The deputy manager will disclose confidential information about staff to others.” Another staff said, “I feel that the manager doesn’tsupport the team and don'tlisten to staff concerns.” A third staff commented, “Staff who raise concerns verbally or officially are either disciplined or made to resign.”

Due to low staff morale this meant that people were at risk of not receiving consistent care and support from the team and could lead into neglect or people not feeling supported or listened to.

After our inspection the service sent us evidence how the provider listened to staff and actions that had been taken to help boost staff morale.

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.

During the assessment, we identified that the registered manager did not fully understand their responsibilities as a registered person. This was evidenced by several and significant shortfalls identified in the areas of care and support provided to people using the service. These shortcomings raised concerns regarding the safety and effectiveness of the care delivered placing people at risk of harm.

The concerns included, inadequate risk assessments and failure to implement appropriate risk management plans for individuals, potentially exposing them to avoidable harm. Gaps in care planning, with care plans not being regularly reviewed or updated to reflect individuals’ changing needs and preferences and failure to monitor and evaluate the quality of care, which meant issues were not identified or addressed in a timely manner.

We saw that regular staff meetings were taking place. These meetings provided a crucial forum for staff to communicate and collaborate effectively, sharing their ideas to contribute to service improvements. For example, after our visit we saw that the registered manager held a meeting with staff to discuss the some of our findings and changes that were required.

There was mixed feedback from the staff team regarding how the registeredmanager managed the home. Some staff felt they were supported however, others felt that the registered manager lacked support and direction and was not in the home long enough to provide support.

The provider sent us further evidence after our inspection, which included up to date risk assessment, care plans and guidance for staff to follow. However, due to this information not being available to staff during our inspection this was a potential risk to people receiving safe care and support

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.

There was a lack of clearly defined responsibilities and oversight mechanisms to ensure care was delivered safely. As a result, risks to people were not consistently identified, monitored, or acted upon.

At our last inspection, the provider failed to ensure there were effective governance systems in place.At this assessment, we found little improvement had been made and there were further shortfalls. For example, Of the 10 care records examined, none had been fully reviewed in relation to care planning and risk management since 2023. This lack of review demonstrates that the provider's audit and monitoring processes are not effective in identifying and addressing shortfalls in care delivery.

On day 3 of our inspection, step was taken to ensure that peoples paper care records were up to date.

We also found widespread and significant shortfalls in other areas such as people’s missing persons information did not have vital details regarding the timeline and when people should be reported missing by staff. People’s mental capacity and best interests’ assessments were not personalised for the individual tasks that were being assessed. Systems were either not in place or robust enough to demonstrate risks associated with medicines were managed effectively. Potential safeguarding concerns were not reported in a timely manner. The call system had not been working for over 3 years and assessments of the system had not been carried out. People were not always supported with their health care needs and their privacy and dignity were not respected. Systems were not always effective in assessing and managing risks to people while they received a service. People were not encouraged to make decisions for themselves and did not always receive care and support that was responsive to their needs.

The provider’s quality assurance systems and checks were not robust.Audits of key operational areas were not effective in identifying and addressing significant issues. This limited the provider’s ability to maintain oversight and ensure the delivery of safe, high-quality care.

However, after our inspection, the provider submitted additional evidence demonstrating that measures were being implemented to enhance the service.

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 concerns raised by external partners such as the local authority were not addressed in a timely manner. This lack of responsiveness indicated weaknesses in the provider’s governance arrangements and posed potential risks to the safety and wellbeing of people using the service.

We have now received evidence from the service demonstrating that actions have been taken.

We were informed that there had been concerns were a person was discharged from hospital with an unknown redness on their body. However, staff failed to contact the hospital immediately to clarify their concerns with them. We also identified potential safeguarding concerns, which had not been reported to the local authority until we requested this action to be taken.

We saw that the service worked with external professionals and agencies, such as people’s GPs, occupational health and speech and language. However, we identified that at times the home did not always complete actions within a reasonable time frame. For example, we discussed with the registered manager that a person’s telecare equipment needed to be completed sooner, as the providers call system was not working. Since our inspection the service had completed this action.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

The registered provider had systems in place to assess, monitor and improved the quality and safety of the services provided. However, this was not always working effectively. We identified a number of concerns where we found improvements were needed. There was little evidence at the time of our inspection that learning took place when things went wrong. However after our inspection we were sent evidence that some actions had been completed.

While staff meetings were arranged, some staff did not consistently feel supported to reflect on practice, engage in problem-solving, or contribute meaningfully to service improvement. The provider has since sent us information on how they have worked with staff and had looked at different ways to ensure staff are being listened to.