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 inadequate. At this assessment the rating has changed to requires improvement. This meant that the governance processes did not always support the delivery of high-quality, person-centred care. The service was in breach of legal regulation in relation to governance at the service.

This service scored 57 (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. They did not always understand the challenges and the needs of people and their communities.

Staff spoke positively about their roles, and people and relatives also shared positive feedback about the caring approach of staff, indicating these values were understood across the team. However, this was not consistently reflected in practice. Records and observations highlighted instances of task-focused care, including the routine delivery of personal care in the early hours of the morning, which did not always align with people’s individual preferences or their usual daily routines within a homely environment. This inconsistency reduced assurance that people’s choices and dignity were always upheld.

Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, there had been a new manager employed since our last inspection where we rated the service inadequate. People, relatives and staff spoke positively about the new manager and described them as approachable and available to provide support and guidance.One relative said, “[Manager] is lovely – very approachable. She is engaged with the staff. She showed great promise after a rocky Autumn. She has steered the ship. You can tell that the staff are happier too.” Another relative commented, “The management of the home was not good – terrible communication. It has really improved. The new manager keeps everyone informed. The previous managers were not approachable, whereas we have had a family meeting with this [manager]. The carers seem happier and the care is better since [manager] arrived.” A third relative told us, “[Manager] seems to have good intentions. I think [manager] is doing a very good job. I’ve not needed to approach them about anything since they have been at the home – as of yet, [manager] hasn’t let us down.”

While leaders demonstrated a caring and supportive approach, this was not always consistently translated into the delivery of person-centred care across the service. In particular, this inconsistency extended to the identification and management of risks, meaning that potential concerns were not always recognised or addressed in a timely way. This reduced assurance that leaders were effectively embedding good practice and maintaining robust oversight of risk.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they could speak openly with the management team and would be supported to raise issues where required.

People and family members also told us they felt able to raise issues or concerns with staff or the management team. This indicated that there was an open and transparent culture where concerns could be shared. A member of staff told us, “Managers are approachable, involved in the home, and support staff when needed.” Another member of staff said, “From my own experience, the management staff at Welshwood Manor are excellent at supporting their employees. They are approachable with any problems you may have and are emotionally supportive.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. At the last inspection we were concerned that the provider did not always value diversity in their workforce and there was a lack of opportunities for staff to provide feedback about the service.

Overall, the majority of staff expressed positive views about working at the service and noted improvements, highlighting a strong sense of teamwork and support. A staff member told us, “I did feel valued at Welshwood Manor with the management staff always having time to praise and tell you how much the carers did and how much they thought of you.” There was an improved positive culture that meant staff felt valued and supported.

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. There was a lack of progress, in some areas, since the last inspection.

The provider had governance systems in place including audits, accident and incident reviews and safeguarding logs. However, some audits were ineffective. For example, care plan audits and accident and incident audits had failed to identify the serious concerns we found on day one of this inspection. Environmental audits had also failed to detect issues around the safety of the environment. The manager responded when concerns were raised and began taking immediate action however, their systems had not identified the issues independently.

We recognised that the manager was making sustained efforts to drive necessary improvements. However, the provider had not ensured sufficient support for the manager or maintained effective oversight of the service at director level or equivalent. There was also no evidence of provider-level audits having been completed. This lack of oversight and structured quality assurance meant risks were not identified or addressed in a timely way, impacting the consistency, safety, and quality of care delivered.

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 always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

At our last inspection, we found significant shortfalls in the quality and safety of people’s care. At that inspection, governance systems could not be fully relied upon to identify shortfalls, monitor the quality of the service, or effectively drive improvements. At this inspection, we found early signs of change; for example, the manager had implemented a system to review incidents and falls monthly. However, these reviews had not been completed since February 2026, and there was no robust or safe system in place for the oversight of the safety of people at risk of choking. This meant there remained a risk that potential harm to people was not identified promptly, opportunities to learn lessons were missed, and improvements were not consistently embedded, which continued to impact on people’s safety and quality of care.