Welshwood Manor

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 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 at the service.

This service scored 36 (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.

There was a challenging culture within the service. We found no evidence the provider had ensured positive culture and professional values were embedded within the staff team. Staff told us of a difficult working environment where they did not feel job satisfaction and receive support. One staff member said, “There has been an increased staff turnover and low morale, sadly leading to an unhappy working atmosphere.” Another staff member told us, “Our previous manager messed quite a lot of things up mostly in regard to staffing and pay roll. Since then, we have not had a proper manager within the home, we don’t really have anyone to go to whether there be an emergency within the home. We have always been given “on call rules” basically stating do not call during certain hours.Which this I would deem to be quite unprofessional.” Another staff member informed us, “We don’t have a proper manager, and I do not know who to contact in emergencies or for any situations that Ifeel need addressing, I have no email or number for the stand in manager at all.” This demonstrated a lack of clear direction and organisation within the service.

At the start of the inspection, the service did not have a manager in post which left the provider to oversee the service including service users’ safety and quality of care. We discussed the shortfalls we found at the inspection with them during both site visits; however, they told us they had no knowledge of adult social care. The provider did not have the skills, knowledge, experience and credibility to lead effectively and did not understand the scale of improvements needed to become compliant with the regulations.

The provider did not understand the audit systems in place and could not be fully relied upon to identify shortfalls and monitor the quality of the service or effectively drive improvements. We found the audits had not been completed since August 2025 and in addition some of the information used to inform audits was not correct. The provider had not identified that tools in place were not completed, for example medicines audits, staff observations and staff dependency calculator.

The provider failed to notify the Care Quality Commission of significant events that had occurred in line with their legal responsibilities.

Although staff knew how to speak up and who to, they did not feel confident they would be listened to and spoke of a culture with bullying and a lack of professional boundaries where staff, who were related, worked together. The provider had failed to recognise this and therefore foster a culture where staff felt assured, they could safely speak up. One staff member told us, “I believe the care remains good however I feel the staff were not always supported by the manager. It was difficult to report concerns due to the close family links.” Another staff member said, “I have some serious concerns regarding Welshwood Manor… if I go to management when we had any, or could find them, it was met with belittling and sarcasm making towards me.” There was a missed opportunity to use feedback and staff experiences to help drive improvements within the service.

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. Staff did not receive regular opportunities to provide feedback about the service. Staff meetings were not always utilised as an opportunity for staff to feedback about their ideas or concerns at the service.

The service was not well-led; there were significant shortfalls in the oversight and leadership which led to poor standards of care. People were at risk of receiving unsafe, poor quality and inadequate support.

The director held a formal role within the company but had no real understanding of how the service operated in practice. They lacked the knowledge and skills necessary to oversee key areas such as staffing, safeguarding, and day-to-day care. As a result, they were unaware of whether appropriate measures were in place to protect people and ensure the service was being run safely and effectively. This lack of oversight meant there was no effective scrutiny of staff practices, safeguarding procedures, or operational management, leaving significant gaps in the governance and safety of the service.

The providerbrought in an interim manager to oversee the service whilst recruitment took place to the permanent position. We found, however, that assurances we were given by the provider and interim manager were not in place when we visited.

Many relatives who contacted us expressed concerns about the governance and leadership. One relative informed us, “I do know that previous managers have had real problems trying to get the owner of the care home to spend money on much needed maintenance, i.e., he finally agreed to redecorating the floor landings and new carpets, the lower floor was completed but the upper floor was half way through decoration when it stopped for nearly a year, with no carpet in the upper staircase landing.” Another relative commented, “They are without a permanent manager at the moment. This makes it difficult. They used to have two units upstairs and downstairs they had an office on each floor, and this was a point of contact which I felt worked well this seems to have stopped. There has been no communication about this to [people]. It would be nice to know who the management is and where they can be found if I need to speak with them.” A third relative stated, “We were told [previous manager] was leaving but we haven’t been told about others leaving and who to contact. I have sent emails to both units and sometimes requested an acknowledgment as this generally doesn’t happen. I did ask one of the senior carers who is now responsible for the care, and they said the three senior carers were.”

The service was not safely well led. In the absence of a registered manager, the provider did not implement an effective governance system and failed to identify shortfalls in the service. For example, in relation to managing safeguarding concerns. This meant risks were not understood or managed which led to an increased risk of poor care and avoidable harm to the people receiving care.

Quality assurance systems had not identified and addressed areas of concern. For example, auditing did not identify concerns relating to the environmental risks such as the lack of a gas safety certificate, potential risks associated with the staircases and the missing fire risk assessment. The systems in place were not effective at always driving forward improvement and ensuring overall safety. For example, there had been a failure to independently identify sufficient staffing levels were insufficient and that the service maintained accurate, complete and contemporaneous records. There were long gaps in some people’s daily notes where no activity had been recorded to demonstrate people were being effectively supported throughout the day.

During our inspection there was no evidence the provider had oversight of concerns at director level or equivalent. This placed people at risk of both abuse and not having care needs identified or met.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Shortfalls in the quality and safety of people’s care were found at this inspection.Governance systems could not be fully relied upon to identify shortfalls and monitor the quality of the service or effectively drive improvements.

There was a lack of robust systems and processes for assessing and monitoring the safety and quality of people’s care. Our inspection identified 5 new breaches of regulations relating to the provision of person-centred care, gaining consent, safe care, safety of the environment and good governance. The lack of effective systems and management meant there was no drive to improve the safety of efficacy of the care and support being delivered.