- Care home
Welshwood Manor
We have taken enforcement action and issued a warning notice on Davard Care Homes Limited on the 22 June 2026 for failing to ensure effective oversight at Welshwood Manor.
Assessment report published 11 July 2026
Contents
Ratings
Our view of the service
Date of Inspection: 11 May 2026 to 19 June 2026. On site visits took place on 11 May 2026 and 2 June 2026.
Welshwood Manor is a care home providing personal care for up to 37 people. At the time of the inspection, 20 older people lived at the service. This inspection was carried out to follow up on the previous inadequate rating and to see if the necessary improvements had been made.
A new manager had been employed since the last inspection. Overall, there were signs of improvement under the leadership of a new manager, however, we also found continued concerns regarding the safety culture and governance.
While the manager was actively attempting to improve the service, systems for monitoring, analysing, and learning from incidents remained insufficiently robust, posing potential risk of harm. Significant risks were identified in the management of choking risks including failures to follow guidance and a lack of staff training. Although the manager took swift action to address these issues during the inspection, these risks had not been identified through existing systems.
Safeguarding processes were in place and concerns were shared appropriately.
At last inspection we were concerned that the care environment was unsafe. We found some improvements at this inspection, however, there remained unsecure external areas, hazardous sheds, and unresolved fire safety concerns.
Staffing levels were sufficient to meet people’s needs, and staff were observed to be caring and responsive; however, there were gaps in staff training and recruitment checks. Medicines were generally managed safely, although there were inconsistencies in recording people’s capacity.
While staff interactions were generally kind and responsive in the moment, the service did not consistently promote dignity, individuality, or person-centred care, with practice still influenced by routine rather than personal choice. Some people were still supported with personal care very early in the morning for staff convenience.
There were also a number of improvements. People’s needs were assessed appropriately, and social engagement had also increased. Leadership showed early positive change, with a new manager described as approachable and committed to improvement. Staff morale and teamwork had improved, and there was evidence of a more open culture where people felt able to speak up. However, leadership oversight and governance still required improvement with ineffective audits failing to identify serious risks, a lack of provider-level oversight, and insufficient support structures.
This service has been in Special Measures since 12 January 2026. The provider demonstrated some improvements had been made and this was clearly a work in progress. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures, however, not all breaches of the Regulations had been met. The service remained in breach of Regulations Dignity and Respect Safe Care and treatment and Good Governance at this inspection.
People's experience of this service
People’s experiences of the service were mixed. There was evidence that people received support from staff who were generally kind, responsive and available when needed, and people and relatives gave positive feedback about relationships with staff and the new manager. However, people were not always supported in a way that fully reflected their individual needs, preferences, dignity, choices or rights.
People were supported to access healthcare services and staff knew how to make referrals when people’s needs changed. Staff worked with healthcare partners and made appropriate referrals when areas of need were identified. People’s communication needs were identified in care plans, and staff used tailored approaches, such as a white board and pen, to support people to express themselves and understand information.
People told us staff were generally available when they needed support. A relative told us, “The carers are around more now – more visible. [Manager] has employed more staff. Most of the staff are permanent and that has made a huge difference to the care.” Staff were observed responding to people promptly, with kindness and patience, and staff understood how to recognise non-verbal cues and signs of pain.
There had been improvements in social engagement and activities. At the last inspection, there were concerns that people spent long periods of time socially isolated. At this inspection, the culture had improved, people were observed engaging socially, and mealtimes were seen to be a positive and social experience. A relative told us, “The activities is another area that has been improved recently. They’ve put up a tennis net and my [family member] joins in – it gets everyone moving without it being a formal exercise class. They play a giant snakes and ladders game on the floor. They are thinking more about how to occupy [people].”
People’s dignity and choices were not always respected. Care was sometimes delivered to meet staff routines rather than people’s individual preferences. Two people were still being assisted with personal care very early in the morning to suit staff routines. Once this was highlighted to the manager, they took action to address this with staff; however, this had not been independently identified.
People were also not always fully protected in relation to consent, privacy and confidentiality. Care continued to be delivered in some areas according to the needs of the service rather than what was in people’s best interests. People’s confidential care records could still be accessed by visitors because the staff office was open and accessible and cabinets containing people’s personal details were unlocked.
People and relatives were able to give feedback and raise concerns. Most relatives told us they would be confident to raise concerns with the manager.
People, relatives and staff spoke positively about the new manager. One relative said, “The previous managers were not approachable, whereas we have had a family meeting with [manager]. The carers seem happier and the care is better since [manager] arrived.”
Overall, people experienced some positive care from staff who were kind, responsive and increasingly supported by an improved management culture. There had been improvements in communication, social engagement, mealtimes and team working. However, people’s experiences were not consistently safe, person-centred or dignified.