Nelson 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 requires improvement. At this assessment the rating has changed to 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 provider was in breach of legal regulation in relation to adequate governance at the home.

This service scored 29 (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.

In the absence of a registered manager the provider failed to ensure senior staff had the support they required in their role. Staff were not aware of any shared visions or strategies to help people receive good quality care. Staff were not supported to fulfil their roles and increase opportunities for people to have good experiences. Staff did not have access to regular staff meetings to discuss the home. Our findings in multiple areas at this assessment as captured through the report led to a negative culture and poor experiences for people.

However, people and relatives remained positive about their care. One person said, ‘‘I do like living here.” A relative told us, ‘‘[Person] is settled here and we do trust the staff which is why we have always decided to keep [person] there; [person] perceives the staff as their family.”

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The provider did not have a clear understanding of the regulations and expectations of their role. They failed to ensure people lived in safe environment and had positive outcomes. The provider failed to maintain oversight of the quality of care being provided and failed to monitor the performance of the previous registered manager. The provider failed to demonstrate they led by example by promoting inclusive behaviours. The provider was present during the site visits and, overall, was receptive to our feedback and took some steps to immediately improve safety in the service following our decision to take urgent enforcement action.

However, we received positive feedback from relatives about the senior staff of the service. One relative told us, “I understand there are problems with management but from our perspective [person] is happy and well looked after, you can see senior staff knows [person] well.”

People did not feel they could speak up and that their voice would be heard.

Although people, relatives and staff felt able to raise concerns they did not always think the provider listened to them. A person said, “I have raised things about my room, but nothing changes.” A relative told us, “I have raised things but nothing changes. Things have not been put in place which would benefit [person]. I don’t think the owner’s care. They are there for the business.” Some staff also didn’t think the providers would listen to their concerns or suggestions and take action to improve people’s experiences.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff were expected to complete core training at home, in their own time. There was a lack of oversight and monitoring of training completed by staff or consideration of any adjustments that may have been needed to how training was delivered to reflect diverse needs of the staff team. Training records showed staff had completed equality and diversity training. However, there was limited evidence to support whether staff knowledge and skills had been assessed following learning to check their understanding and how this had been applied in the service.

Staff told us they worked well together as a team and supported each other during the absence of management support. A staff member told us, “The morale is low, due no management support. We do our best and support one another to ensure people get the care they need, but it could be better.”

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 an effective processes or systems in place for the monitoring of the quality of care provided to drive improvements. The provider told us the previous registered manager had not fulfilled their role nor completed all required tasks expected of them. However, the provider was unable to share with us how they had come to this judgement and what processes they had in place to monitor the quality of work completed by the previous registered manager. The provider was unable to share with us how they maintained oversight of the service besides advising they visited the home on a regularly basis. The previous manager left the service in January 2026. A senior staff member acted up into the role of manager but was expected to complete management duties in addition to undertaking caring duties, which, in addition to limited staffing levels, compromised their ability of being able to effectively lead the home, as was required. This meant there was limited management of the home.

There was poor governance and a lack of effective monitoring of the safety of the environment, safeguarding, care documentation, people’s needs, risks, medicines, responding to concerns and ensuring people’s rights were always promoted. The provider had failed to follow their own procedures and failed to meet the requirements of current legislations, as they had not submitted notifications to CQC and the Local Authority in relation to notifiable incidents.

During this assessment, we found multiple concerns within the home and urgent enforcement action was undertaken. These shortfalls had not been identified or acted upon in a timely manner. Failure to maintain oversight of quality monitoring processes placed people at risk of receiving poor care.

The provider was advertising for a new manager and told us interviews had been scheduled in the coming weeks.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The Local Authority had undertaken several monitoring visits to the home since January 2026 and had engaged with the provider, sharing their concerns in areas they had identified for improvement. The Local Authority had worked with the provider and staff to support improvements; however at the time of this assessment, we identified the provider had failed to maintain safe, appropriate standards of care and the service was in breach of regulations.

The provider had also failed to respond and fully address the recommendations from a Fire Risk assessment conducted in 2021. This placed everyone at the home at risk of harm in the event of a Fire.

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.

At the time of assessment, we found multiple areas of concern in the home that had either not been identified or addressed. Urgent actions were taken to safeguard people from risk of harm.

There had been a lack of consistent staff meetings, supervisions and observations of staff practices to ensure staff received the support and feedback about their performance to help drive improvements in the home.

Processes were not implemented effectively to enable a consistently good service to be provided to people and improvements had not been made where required. Audits were not effective in identifying where improvements needed to be made and the service was not meeting the fundamental standards we expect from care services. Although the provider took action to make improvements in response to our feedback following this assessment, we cannot be assured these improvements will be sustained and embedded.