Archived: Lower Bowshaw View Nursing 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 inadequate. At this assessment the rating has remained inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service continued to be in breach of legal regulation in relation to good governance.

This service scored 36 (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 shared vision, strategy and culture 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. The current management team had been faced with a poor staff culture, where staff were reluctant to change and were not always accepting of new systems and processes. The management team were working to improve the culture of the service but were experiencing difficulties. This meant improvements in the service were slow.

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 management team consisted of the manager, a clinical lead, nurses and senior staff, with a consultancy company overseeing changes and trying to improve the service. Some senior care staff and nursing staff were reluctant to change and were not proactive at ensuring new processes were being used effectively. We spoke with people and their relatives and found nobody knew who the manager was but 2 people thought they would recognise them. One person said, “I don’t know who the manager is, but I would ask to speak to them if I had a problem, I just haven’t ever hada problem.”

Staff did not always feel they could speak up and that their voice would be heard. At our last assessment we found staff had no regular, formal supervision to enable them to raise issues or request support. At this assessment we found minimal improvement. The manager had devised a supervision and appraisal schedule, but most staff had still not received this support. Staff told us they felt supported by the new management team. Staff had access to a whistle blowing policy.

Processes were in place which helped to protect the rights of staff under the Equality Act. This helped to create a more equitable and inclusive organisation. However, lack of oversight by the provider meant staff were not always supported. Staff were not regularly supervised, and some training was not up to date. The current manager had a schedule in place to address this.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. We looked at quality monitoring, audits, and governance of the service. The governance framework had not always identified issues that required attention to ensure the safety of people living at the service. The systems were not embedded into practice and were not sustained. For example, a staff recruitment file audit was in place, but this had not always been effective in identifying concerns we found during our assessment. There were some instances where issues had been identified but timely action had not been taken to address them. The management team were operating with 2 care management systems, 1 being electronic and the other paper based. This was causing some concerns with consistency.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement. We received negative feedback from external professionals who felt the service had not really improved since our last assessment. One professional said, “We continue to experience a significant issue regarding contacting Lower Bowshaw View. Telephone contact is very difficult, with the phone not being answered on a regular basis. This has been a particular issue when trying to screen safeguarding concerns and establish immediate risks and protection plans. Emails are responded to, however not always and not always timely. There is still work to be done to ensure partnership working is effective and person centre to ensure essential information is passed on and communication to relevant partners.” We raised these concerns with the manager who said, “We get feedback during meetings, visitors to the service give feedback, for example we received some feedback from families around not being able to contact the home and sometimes having to wait to get in, we employed a receptionist to support this.”

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. Until July 2025, the provider had not taken action to address the shortfalls identified at our last assessment in March 2025. A new management team commenced in July 2025 and with the support of a consultancy company had started to implement systems and processes to help them manage the service effectively. However, during our assessment we found not enough improvement had been made, and the provider remained in breach of regulation, and the current enforcement action remained.