By the time a service reaches the stage where enforcement is being considered, commissioners are raising concerns or external support is brought in, the issues are rarely new. What has changed is not the level of risk, but its visibility. Turnaround work exposes you to services where that visibility can no longer be avoided.
The gap between what is believed to be happening and what is actually happening has become too wide, and the systems that once supported the service are no longer dependable. What becomes clear very quickly is that the same patterns recur regardless of provider, location or service type. These patterns are significant because they are rarely unique and can often be prevented.
Failure is rarely about one issue
In most failing services, there is not a single point of failure. Instead, reliability gradually diminishes across various areas of practice. Care plans may be in place but often lack consistency or meaningful detail. Risk assessments might be available but are not reviewed regularly or incorporated into daily care. Medication procedures may be technically established but are not robust in practice, with gaps in stock management, PRN protocols or recording.
Appointments may be scheduled but not always followed up, and safeguarding concerns may be dealt with individually without being looked at collectively. None of these issues alone will necessarily destabilise a service. The risk occurs when they coexist without proper oversight, leading to small gaps interacting and widening one another. This is often the root of service failure. Not a single major issue, but several smaller ones that have not been combined, understood or tackled in a co-ordinated manner.
The difference between activity and grip
One of the most consistent findings in turnaround environments is that services are not inactive. In many cases, staff work hard, managers are present and there are processes in place that indicate a level of control. The challenge is that activity is not the same as grip.
Grip is about being able to understand, at any given point in time, whether the service is safe, where the risks sit and what is being done about them. It requires information that is current, accessible and meaningful.
In services that are struggling, that grip is often missing. Information exists, but it is fragmented across systems or buried within documentation. Audits are completed, but they are retrospective and do not always translate into immediate action. Action plans are written, but they may not be embedded into daily practice.
The key test is a simple one – can the service clearly articulate, on any given day:
- Which people are at the highest risk?
- Where there are gaps in care delivery or follow-up?
- What medication risks exist, including stock or administration issues?
- Where staffing pressures may impact safety?
If that cannot be answered with confidence, then governance is not operating in a manner that ensures safe care. A helpful check for providers is to imagine themselves within their service and ask, ‘If the registered manager was not on shift today, would the team still be able to recognise and respond to the highest risks?’ If the answer is no, then the issue is not effort, but visibility and structure.
Workforce instability and decision-making
Workforce challenges are often seen as issues of recruitment and retention, but what becomes evident in turnaround work is how deeply they influence decision-making and consistency.
Where there is high staff turnover, reliance on agency workers or gaps in leadership, there is often a corresponding variation in how care is provided and how risks are managed. Policies may be interpreted differently by various staff members, escalation procedures may not be followed consistently and crucial information may not be handed over effectively. This creates a situation where the same issue can be addressed in different ways on different days, depending on who is on shift.
Over time, this inconsistency raises risk and diminishes confidence, both within the team and among external stakeholders. Stability in the workforce is therefore not merely about numbers. It involves creating an environment where decisions are made consistently, recorded clearly and followed through.
Culture becomes visible under pressure
Culture is often described in abstract terms, but in failing services, it becomes highly tangible. It is evident in how staff respond to concerns, whether issues are openly discussed or minimised and whether individuals feel able to speak up without fear of blame or consequences.
A common feature in turnaround environments is a disconnect between what the service believes it is doing and what happens in practice. Safeguarding concerns may be rephrased rather than explored, incidents may be recorded without proper analysis and staff may be aware of issues but feel they cannot raise them. Without tackling these underlying behaviours, changes to process alone are unlikely to be maintained.
Communication is a big part of this. In struggling services, it is not uncommon to see staff spoken to in a reactive, dismissive or overly critical way when things go wrong. While this often comes from pressure rather than intent, it can quickly create a culture where people become defensive, less likely to report issues and more focused on avoiding blame than improving practice.
In contrast, services that stabilise well tend to create environments where concerns can be raised openly, mistakes are explored rather than punished and staff feel supported to learn and improve. This does not remove accountability, but it changes how it is applied.
What makes a difference
Stabilising a service does not involve introducing many new systems or processes. Often, the necessary frameworks are already in place. The real challenge lies in ensuring they are used consistently, understood by staff and linked in a way that provides a clear and accurate view of the service.
One of the most effective interventions is making information visible and actionable daily. Structured review processes, such as brief clinical or operational huddles, enable teams to address key risks in real time. This includes medication exceptions like low stock or missed doses, changes in people’s needs, outstanding appointments and staffing pressures. The value of these processes comes from their consistency and their focus on immediate action rather than retrospective review.
For example, in one service, repeated medication errors were initially treated as isolated incidents. When reviewed collectively through a daily huddle, it became clear that the underlying issue was inconsistent stock management and unclear PRN guidance. Once these issues were made visible and addressed systematically, the pattern of errors reduced significantly within a short period.
Equally important is ensuring that systems are aligned. When information is stored across multiple platforms, inconsistencies can easily occur, especially around key risks such as allergies, behaviours or clinical conditions. Aligning these systems reduces the chance of errors and supports more consistent care.
Clarity of expectation also plays a key role. Staff need to understand what good practice looks like, what is expected of them and how this will be monitored and supported. This requires visible leadership, regular supervision and timely feedback. It also needs a willingness to address behavioural issues as they arise, rather than relying solely on additional training or process changes.
What to look for early
For providers looking to avoid reaching a point of escalation, there are some early indicators that are worth paying attention to.
These are seldom dramatic, but they remain consistent:
- The same issues appearing repeatedly in audits without clear resolution.
- Gaps between what is recorded and what staff can describe in practice.
- Increasing reliance on informal knowledge rather than documented systems.
- Delays in follow-up actions, particularly around appointments or clinical input.
- A sense that issues are being managed individually rather than understood collectively.
These signals often occur before more serious concerns are recognised. Detecting them early enables intervention before they become ingrained.
Lessons for prevention
Although turnaround work is frequently reactive, it offers valuable insight into prevention. The problems observed in failing services are rarely unpredictable. They usually follow recognisable patterns, influenced by common pressures such as workforce instability, competing priorities and increasing complexity of needs.
Providers’ opportunities lie in recognising these patterns early and implementing simple, consistent mechanisms to maintain oversight. This includes gaining a clear understanding of daily risks, ensuring systems are actively used rather than passively maintained and supporting staff to make consistent, well-informed decisions.
Maintaining stability
Improvement is often seen as a project with a clear start and finish. Stability requires ongoing effort. Services that are capable of sustaining improvement tend to concentrate on a few key principles. They implement straightforward, repeatable processes integrated into daily routines. They establish clear lines of accountability, so it is always clear who is responsible for what. They make sure leadership is visible and actively involved, and that issues are identified and addressed early.
None of this is particularly complex. The challenge lies in maintaining it consistently, especially when services are under pressure. That is often the difference between services that recover and those that persist in struggling. It is also where the greatest opportunity lies, because the earlier these patterns are recognised, the easier they are to address.
How do you maintain oversight and stability in your service? Comment on this feature or join the conversation to share your approach.
Lucy Corner is Managing Director at Cornerstone Care Solutions. Email: [email protected] Linkedin: @Cornerstone-Care-Solutions