Whetstone Grange

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.

During this inspection we identified a breach in regulation in relation to good governance.

This service scored 54 (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.

At the time of our inspection not all the staff shared the provider’s vision and values or their commitment to ensuring people received safe, good-quality care. For example, we saw staff undertaking unsafe moving and handling procedures, and people told us staff were not always respectful and kind.

Some people and relatives were aware of tensions in the staff team. Professional boundaries had not always been observed. A person said, “Morale is very bad. Staff talk to me, they come in and vent.” A relative told us, “Some days morale’s not great. The staff are lovely but overworked.”

However, most staff were keen for the service to change. They wanted to work with the provider and be part of the service’s improvement journey. They were committed to the people they supported and determined to ensure they received the best care possible in an inclusive and empowering environment.

Not all managers understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

At the time of our inspection the service did not have a registered manager. Some people and relatives were unclear about who was managing the service and when they were available. A person said, “We don’t see much of them [managers], and I’ve not met the new one.” A relative told us, “I would say [the service] is well led but the managers aren’t here a lot.” Others were confused about who was managing the service. Some said the service had a new manager who was off work. Another person thought the service had a new manager who was ‘downstairs quite a bit’.

There was no information in reception, for example a staff photo display, to show staff job titles, their names, and what they looked like. This made it difficult for people, relatives, and others coming to the service to identify who was on duty and who was in charge.

Managers did not always have the skills, knowledge, experience, and credibility to lead effectively. They failed to ensure the organisational vision was delivered, and risks were professionally managed. Managers had not identified and/or addressed the safety and other issues we found at this inspection. These included unsafe moving and handling and other risks to people, training deficits, medicines storage issues, and poor records keeping.

Managers and staff made positive comments about the provider who they said was easy to contact, listened to them, and supplied resources to the service on request.

The provider was planning to bring in a new experienced manager to work full-time at the service and be visible and available. Following our inspection this new manager was appointed and started work at the service.

People and staff did not always feel they could speak up and that their voices would be heard.

The provider had complaints procedures for both staff and members of the public to follow if they wished to raise concerns. Despite this, in the three months prior to our inspection, CQC received two anonymous complaints from people who said they were staff at the service, and one anonymous complaint from a person who said they were a relative of a person who lived there.

At our inspection we found evidence that some of the anonymous concerns had substance, and people had been put at risk. In addition, a person told us staff had complained to them, rather than going to the provider. This indicated that staff were not always using the proper channels when they had concerns about the service.

However, during our inspection, most staff said they would speak out if they needed to. A staff member said, “If I had any concerns I would go to a senior or manager, if [they didn’t do] anything I would go to CQC.” Another staff member told us, “Most staff were more than happy to speak up.” However, a further staff member said they had lost confidence in the management of the service and did not feel safe enough to raise concerns.

The provider had reached out to staff at an open forum where they had the opportunity to share their views. The provider said that despite this a minority of staff had low morale, possibly due to changes in working conditions and this could explain why they were taking concerns elsewhere.

The lack of formal supervisions, appraisals, and staff meetings had also impacted on staff morale and taken away opportunities for them to speak out. The provider was addressing this issue.

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’s recruitment process was equality monitored to ensure it was fair for potential candidates. Staff with needs relating to protected characteristics received ongoing mentoring and support if required.

The provider was committed to diversity, equality, and inclusion. Staff from diverse backgrounds said they were happy working at the service and felt valued and supported. A staff member told us, “I’ve been made welcome and if I don’t understand something the other staff always help me.”

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.

At our last inspection the governance systems were ineffective as they failed to identify shortfalls within the service. At this inspection the governance systems remained ineffective. Shortfalls had not always been identified or addressed.

Managers had not always followed the provider’s safeguarding policies and procedures. In July 2025 only 1 out of 7 safeguarding incidents had been reported to CQC and the local authority. This meant that CQC and the local authority were not aware of these incidents and did not to have the opportunity to act if this was deemed necessary.

Staff supervisions and appraisals has not taken place in line with the provider’s policies and procedures. This was identified in the provider's ‘monthly operating report’ for July 2025. However, there was no analysis as to the reasons for this, nor was there any recorded action as to how this should be addressed.

We discussed these shortfalls with the provider who said they were committed to improving the service and were following a service improvement plan. This would be amended as necessary to include issues raised at our inspection.

The provider’s audits included a ‘daily walk around report’, a ‘daily operating report’, and a ‘monthly operating report’. We found shortfalls with all these audits.

The manager’s ‘daily walk around report’ had not been completed consistently. For example, in August 2025, it had only been completed on 12 of the 19 days prior to our inspection. This meant shortfalls at the service and issues with people’s safety may have been missed.

The provider’s ‘daily operating report’ was not always accurate. On 28 July 2025 the report stated the temperature in the medicines room had been checked and were within an acceptable range. However, on that day the service's daily medicines room temperature monitoring form recorded temperatures ranged from 24.7c to 27.9c (the recommended maximum being 25c). In addition, it was evident from the monitoring form that excessive temperatures in the medicine room were a regular occurrence in July 2025. This had not been effectively addressed by the provider at the time of our inspection.

The provider's ‘monthly operating report’ for July 2025 confirmed that the medicines temperature log had been checked. However, this log included multiple dates when temperatures exceeded the recommended maximum. Despite this the report did not acknowledge this shortfall or ask for any action to be taken.

Systems and procedures to manage a person’s admission to the service were unsafe and ineffective. This put a person at increased risk of harm as staff did not have the information they needed to keep the person safe when they were admitted to the service. In addition, the person’s admission form was not signed or dated, so we were unable to tell who completed it and when.

The provider understood their duty to collaborate and work in partnership with people, other organisations and services. They shared information with partners and collaborated for improvement.

The provider was working with the local authority to improve the service. They had shared information, both positive and negative, with local authority staff to ensure they understood the challenges the provider was facing.

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. They did not always actively contribute to safe, effective practice and research.

Managers did not have a good understanding of how to make improvements happen. Shortfalls at the service, where identified, had not been promptly addressed. For example, moving and handling, infection control, and supervision issues were still outstanding.

However, the provider had listened to people and relatives and made improvements. People and relatives had said the premises were cramped and poorly decorated, so the provider refurbished the premises and turned storerooms into further communal areas. People and relatives had also asked for an outdoor area, and the provider had created a large, secure garden space for them to use. In addition, the provider had arranged for a minibus to come to the service weekly to take people out. A relative said, “I like the fact they’ve just included the minibus into the home. And I love the garden, it means I can take [person] there.”