Abbeyfield Lear 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 good. At this assessment the rating has changed to requires improvement.

This meant the service was not consistently managed and well-led. Leaders and the culture they created did not always promote high-quality, person-centred care.

This service scored 50 (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. For example, the provider was unable to clearly explain how they embedded the vision and values of the service into day-to-day practice. The provider told us, "The manager implements values with staff." We discussed this with the registered manager however they were unable to explain this.

The manager told us they worked with people and their representatives, such as family members, to ensure a culture focused on enabling individuals to enjoy fulfilling lives.
 

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 lacked the skills, knowledge, experience, and credibility needed to lead effectively, and they did not always do so with integrity, openness, or honesty to ensure risks were professionally managed. For example, the registered manager told us they did not receive consistent support from the provider or the board of trustees. The governance systems in place were not effective. Audits carried out by the provider/registered manager did not identify the concerns we found during our assessment.
When we asked the provider about the governance systems in place, they responded, "We have a chat." This response did not demonstrate the presence of any structured or formal oversight arrangements and therefore did not provide assurance of effective governance. In addition, the provider did not demonstrate a clear understanding of the requirements or recommendations made by us during the assessment.
 

The provider did not always foster a positive culture where staff felt empowered to speak up and have their voices heard. While some staff said they could raise concerns with their immediate manager, they lacked opportunity for formal discussions, with records showing only two staff meetings held per year. One staff member told us, “Lots of support from our immediate manager but not so much above." This infrequency of staff meetings significantly restricted open communication, the escalation of concerns, shared learning, and collaborative problem-solving.
We spoke with staff who had mixed views regarding the service. Comments from staff included, "The choice of cuisine could be improved to include more variety," "Choice could be a bit more varied," "We could sometimes do with an extra carer on as we have 4 or 5 people who require 2 carers." These issues were not regularly discussed as a team, which limited shared learning. The registered manager was responsive to feedback provided and has since implemented regular staff meetings to improve communication and engagement within the team. One staff member told us they can raise concerns with the registered manager and felt these would be dealt with however they stated they did not feel they had the same support from managers above.
 

The provider was able to demonstrate they valued diversity within their workforce and actively worked towards an inclusive and fair culture.
The provider demonstrated a commitment to promoting equality and fostering an inclusive and fair workplace culture. Staff described a positive and respectful environment where everyone felt valued and supported. Although the provider’s recruitment practices did not yet fully reflect a proactive approach to attracting a diverse workforce, staff retention was high, and many team members had worked at the service for a significant length of time. This continuity contributed to a strong sense of team cohesion and mutual respect. Staff reported feeling included and treated fairly, and there was evidence staff had completed equality and diversity training.
 

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. For example, the providers governance systems failed to effectively assess and monitor the quality and safety of the service. Risks to people were not identified and mitigated, including risks associated with management of medicines, infection prevention and control, staff recruitment and record keeping. Events including accidents and incidents were not analysed to determine the cause and any measures required to reduce are occurrence of the event. The provider failed to share information about risk with others including local authorities and the Care Quality Commission (CQC) as required by law. This included multiple incidents of a serious nature. We identified a breach of regulation 18 (Notification of other incidents)
Leaders were unable to clearly explain or demonstrate their governance framework, which limited accountability and hindered the provider’s ability to monitor and drive improvements effectively.
Staff had completed training for infection prevention and control and the registered manager had completed audits which were ineffective as they did not identify any of the concerns we found. We were unable to view any cleaning schedules the service had in place.
Staff worked well together as a team. However, we found there was uncertainty among staff about their roles and responsibilities, which led to inconsistencies in how care and support was delivered. For example, domestic staff were unclear about who was responsible for cleaning pressure cushions and mattresses, which posed a risk to maintaining hygiene standards and infection prevention. These issues highlighted the need for stronger leadership, clearer communication, and more robust oversight to ensure people consistently received safe and appropriate care. Despite these concerns, all staff we spoke with felt adequately trained and supported. They spoke positively about the registered manager and leadership team. Staff comments included, “People are safe and well looked after,” “There are always enough staff on duty” and “The team work well together.”
The provider was unable to demonstrate what arrangements were in place to ensure staff had appropriate access to support during out-of-hours emergencies. For example, we reviewed the provider’s business continuity plan and found it did not include disaster planning or identify an alternative location for relocation in the event of an emergency.
 

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. For example, professional advice was not always followed in relation to people’s care needs. We found examples where steps had not been taken to involve other health and social care professionals when making important decisions about people's health and wellbeing.
Staff engaged with communities. They used these networks to identify new or innovative ideas that could lead to better outcomes for people. One staff member told us, “I try and keep (Name) in touch with her church via Zoom” and “There is an emphasis on bringing the community into the home.”.
Family members and friends could visit people without restriction. One relative told us, “Family can visit any time. I am always made to feel welcome, and staff know me now too.”
We reviewed activity plans and observed people participating in a range of activities. People appeared to be actively engaged and thoroughly enjoying their time, which contributed positively to the atmosphere and overall sense of wellbeing within the service.
One staff member told us about a variety of planned activities, they said, "June activities planned are a visit from a local pre-school, a musical session provided by popcats, we have a pamper afternoon three times a month, and church service. We have booked Owl Man for June."
 

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. For example, the providers quality assurance systems and processes did not promote learning and improvement across the service. There were missed opportunities for learning following events and audits and checks failed to identify areas for improvement.
There were no reflective meetings or structured opportunities for staff to come together to share ideas and discuss improvements.
The provider was slow to respond to an environmental risk we identified, involving a trip hazard. Despite the potential for harm, it took three weeks to address and repair the issue after we had raised it, indicating a delay in taking timely action to mitigate known safety risks.
We raised concerns about cleanliness and the incorrect disposal of personal protective equipment (PPE). However, this had not been actioned when we returned the next day. Following our visit, the registered manager took some corrective action, including providing training to staff on the correct disposal of PPE. This aimed to improve staff awareness and reduce infection control risks.