Archived: Blossoms Care Home Limited

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 breach of legal regulation in relation to governance and oversight at the service.

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.

At our last inspection we found that the culture of the service was poor. At this inspection, we continued to identify concerns. There was a closed culture at the service. A closed culture is a poor culture in a health or social care setting that increases the risk of harm, human rights breaches, and abuse. The provider and NI had failed to make improvements to the service, including addressing the culture of the service.

Staff did not demonstrate a positive listening culture that promoted trust and understanding between them, and people using the service. For example, we observed multiple people distressed, and seeking support. Most staff did not recognise or acknowledge this, walking past people, or not approaching people when distressed. On one occasion this led to an incident whereby one person nearly struck another with their walking frame.

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.

At our last inspection we found that leaders did not have the skills or knowledge to lead effectively. At this inspection, we continued to identify concerns. The provider had failed to ensure that there was capable leadership within the service. There was no registered manager in place, and there had not been a manager registered with the CQC since May 2024. It is a condition of the providers registration with the CQC that they must have a manager registered with the CQC.

Leaders had not been alert of examples of poor culture that may affect the quality of people’s care and have a negative impact on staff. Staff morale was low. Since our last inspection the NI and provider had removed the role of the senior carer, which left staff without a clear structure of accountability.

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

At our last inspection we found that people were not always supported to ensure that their voice was heard. At this inspection, we continued to identify concerns. Staff we spoke with did not feel they could confidently raise concerns without fear of doing so. Whilst the NI had organised team meetings, staff did not feel able to raise their concerns, or that their concerns would be acted on. Staff had not shared concerns of poor practice, in relation to supporting people who could become distressed, or staff using unsafe manual handling techniques.

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.

At our last inspection we found that there was issues identified with the staff team working together. At this inspection, we continued to identify concerns. Leaders had not ensured they had taken steps to remove bias from practices to ensure equality within the workforce. The provider and NI failed to ensure that staff were recruited safely, ensuring that equality and diversity was captured and considered. We could not be assured that staff human rights were considered. The provider and NI had not proactively engaged with staff. Although team meetings had taken place, these had not created an environment where staff were able to have their voices heard without fear of retribution.

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.

At our last inspection we found there was a lack of effective governance and oversight. At this inspection, we continued to identify concerns. The provider had not ensured that there were sufficient oversight and governance processes in place to make improvements at the service. They did not ensure there were systems in place to make improvements. The providers audits and checks failed to identify numerous and widespread issues including, poor medicines management, a lack of risk management and mitigation, poor recruitment practices and a lack of staffing, training and competency checks. The provider failed to make and sustain any improvements, and more areas of concerns had been identified since our last inspection.

The provider did not understand their regulatory requirements. Services that provide health and social care to people are required to inform the Care Quality Commission, (CQC), of important events that happen in the service. This enables us to check that appropriate action had been taken. The provider failed to inform the CQC when there was a police incident at the service.

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.

At the last 2 inspections, we found that staff had not always worked in partnership with other organisations. At this inspection, we continued to identify concerns. Staff failed to identify when people had a significant, unexpected change in their weight and make the necessary referrals to healthcare professionals. When people had seizures, these had not always been documented to ensure that this information could be shared with the necessary healthcare professionals to monitor people’s health.

We received feedback from a healthcare professional, which detailed concerns relating to risks to people not being well managed, observations of poor manual handling techniques, and a lack of staff.

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.

At our last inspection, we found that there were not effective systems to ensure that lessons were learnt. At this inspection, we continued to identify concerns. The providers incident log had not been updated since March 2025. The NI told us there had not been any incidents since then. However, we identified that incidents had occurred, but these had not been captured on the incident log. The provider and NI failed to identify these incidents for themselves within daily notes and told us staff had not informed them of the incidents. There was a lack of professional curiosity to follow this up and ensure that information remained accurate and correct.

Despite multiple people who could become distressed the provider failed to identify that staff could benefit from additional training and support and implement this for them. We observed staff lacking the skills to support people with their distress.

As part of the conditions we placed on the providers registration, they sent us monthly reports to inform us of progress and improvements within the service. The providers report they shared with us from October 2025 indicated that there were no concerns and they had addressed the concerns we had raised at our previous inspection on 17 January 2025. We found this was inaccurate and the provider missed the opportunity to identify and implement improvements at the service. This demonstrated an inadequate governance system. The providers lack of oversight and insight into the risks and challenges of the service, and the significant risks to people had a major impact on people’s safety.