Adelphi Residential Care Home

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 management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of the legal regulation in relation to good governance.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The vision of the service was to provide good quality care; the registered manager sought to make sure people’s lives were as similar as possible to how they lived prior to moving into the home. The recruitment process considered the values and ethos of staff to make sure they understood the challenges and needs of people supported in the home. Staff said they felt listened to and enjoyed their jobs.

Not all leaders understood the context in which the provider delivered care, treatment and support.

Audits conducted on quality of care were not effective in making sure risks or concerns were identified or actioned. However, the registered manager had been in post for several years, and staff were positive about support received from leaders. The registered manager could access further training and development to supplement their knowledge.

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

Staff said they felt able to speak up and did so. They thought they would be listened to and anything they raised would be acted upon. The provider had an appropriate whistleblowing policy.

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.

The provider had appropriate equality, diversity and inclusion policies and procedures. Staff said they were treated equally and did not have any concerns.

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.

Improvements were required regarding governance of the service, the premises and facilities, and assessing risks to people. Although there was evidence some audits had been undertaken, these did not identify or address issues found during the assessment. Some audits appeared to have ceased in December 2025. There was no system to monitor Deprivation of Liberty Safeguards applications and renewals, and we found some gaps in recruitment processes. Although no high-risk incidents had occurred, for example injuries from falls, we found 1 incident that should have been notified to the CQC had not been. We found no evidence of harm and the registered manager assured us changes to the environment would be made which will be checked at the next assessment.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider established partnerships with the local community and worked closely with another care home and manager to share good practice and learning from events. There were links with local businesses and shops, and a member of the Catholic Church visited to provide weekly communion. Other faith groups were also represented. The registered manager organised trips and volunteers and musicians visited regularly.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The registered manager was supported by the provider to attend further training and development. The registered manager kept up to date with current guidance and best practice through attendance at forums and conferences and received learning from events information. Updates were shared with staff via team meetings.