Philip Cussins House

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 provider 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. The provider was unable to provide us with their vision and values statement. Staff were unsure as to whether the provider had this. However, staff described the home as being friendly and welcoming.

Not all leaders 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. The registered manager had recently retired, and the deputy manager was overseeing the home until a new manager was appointed. There had not been an effective transition or handover to ensure the interim management arrangements were effective, such as a clear understanding of the quality assurance procedures expected.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There was a whistle blowing policy, which was reviewed and updated regularly. Staff were confident to raise concerns.

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 an equality and diversity policy and staff confirmed they were well 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. The provider did not have a documented or structured approach to quality assurance. The interim management were unfamiliar with the quality assurance processes and lacked knowledge of what the process should be. The provider was unable to evidence consistent and robust quality assurance audits and checks were completed. Some audits were not available, such as in relation the kitchen and catering, hand hygiene and infection control. Other audits had not been completed recently. The most recent documented care plan audit was dated December 2023 and the most recent in-depth medicines audit dated July 2025.

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 home had good links with the local community and people told us they often went on outings in the community, such as to visit the local Quaker house. People told us students from a local college visited to spend time with them and have a chat.

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. The provider lacked effective systems to check on the quality of people’s care, ensure lessons were learnt and improvements identified. The provider did not have an improvement plan for the home.