Greenacres 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 legal regulation in relation to the governance arrangements in the home.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

We found that the registered manager promoted a caring culture, and this was reflected in the positive and respectful interactions we observed between staff and people using the service.

However, the registered manager’s and provider’s competency in governance and oversight required improvement. Key safety and quality systems were not consistently embedded or monitored. For example, medicines oversight lacked the rigour expected.

Overall, while the registered manager demonstrated caring leadership, further development in governance and quality assurance was needed to ensure the service is consistently well‑led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Governance arrangements were not effective, and leaders did not have oversight of key risks within the service. Audits failed to identify fundamental issues, including missing mental capacity assessments, absent medicines profile/identity sheets, poor controlled drugs management, and outdated infection control policies. These problems were clearly evident in everyday practice but had not been recognised or acted upon through governance processes.

Action plans were completed but did not include timescales, which meant there was no accountability for when improvements needed to be made. As a result, important actions were not tracked or evaluated, and concerns remained unaddressed.

There was also a significant lack of provider‑level oversight. Core systems such as staff supervision, safeguarding and MCA training compliance, medicines audits, and stock checks had not been monitored effectively. Training gaps and missed supervision had not been escalated or addressed.

Importantly, some systems that had previously been in place had not been sustained. These included medicines profile sheets used to support safe administration, and the routine completion of mental capacity assessments when restrictions were applied. These basic safety systems had fallen out of everyday practice without detection by the registered manager or the provider.

Because these governance failings were widespread and longstanding, leaders did not have accurate or reliable information about the quality or safety of care. Without effective oversight or sustained systems, the service was unable to ensure that risks were identified, monitored or reduced.

Overall, the provider’s governance arrangements were not fit for purpose, and the lack of robust oversight placed people at risk of unsafe or inconsistent care.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

We found limited evidence of continuous learning or innovation within the service. Core systems had not developed in line with current guidance or best practice. For example, the infection control policy was out of date, and important safety processes such as medicines profile sheets and mental capacity assessments had previously been in place but were not sustained.

Audits and quality checks did not drive improvement and failed to identify obvious concerns, including issues with controlled drugs, PRN protocols, training gaps and missing documentation. This indicated that learning from oversight activities was not embedded into practice.

The service lacked systems to support continuous learning or keep practice aligned with current national guidance. Key policies, such as infection control, had not been updated, and core governance processes had not evolved with best practice. Audits and quality‑assurance checks did not identify obvious risks, particularly in medicines management and staff training, and were not used to drive improvement. Overall, leaders had not created a culture of learning or modernised governance systems, limiting their ability to deliver consistently safe or evidence‑based care, despite staff providing kind day‑to‑day support.