Duke Street Bungalows

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 was rated 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.

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.

The provider did not always implement a positive and embedded shared vision, strategy and culture that was based on national policy and best practice.

As reported on throughout this report, improvements were needed to ensure the right support, right care, right culture guidance was always considered and implemented to ensure people were involved with all aspects of their care and a true model of person centered care was delivered. For example, although people participated in many activities they enjoyed, it was not always clear they were always meaningful to the person. The registered manager showed us a sensory room that had been built in 1 of the bungalows. We saw people using this and they appeared relaxed in this environment, however using this facility as a community-based activity would increase people’s integration and stance in living an ordinary life.

In some bungalows we saw there was an emphasis on people doing tasks for themselves when they could, such as taking their laundry to their rooms and putting this away. However, in another bungalow a person requested some make-up to wear and staff went to their room and fetched it for them. This potentially restricted the person’s choice about their appearance and did not promote a culture where independence was consistently maximised.

However, the registered manager told us about their direction and culture of the service, they told us, “They are always off out enjoying themselves, they have fantastic opportunities”. Staff told us the registered manager supported them and encouraged them to speak openly and share concerns to create a positive environment for them to work within.

Not all leaders understood the context in which the provider delivered care, treatment and support.

At our last inspection in 2019 we made the following recommendation. We recommend that the service seeks advice and guidance from a reputable source, about supporting people to express their views and involving them in decisions about their care, treatment and support. At this inspection, we found some people were not always involved with all aspects of their choices and decision making and improvements were need to ensure how they expressed their views were considered and captured. This meant the provider had not taken the action we recommended they take to make the necessary improvements to the care and support people received.

However, people, relatives and staff spoke positively about the leadership team and how the home was run. One person said, “I like [registered manager]. A relative told us, “The manager is nice, she listens. Any concerns she would deal with it”. Staff raised no concerns to us and felt it was a nice place to work and felt supported by the registered manager.

There were systems in place to ensure staff understood their roles and responsibilities when they needed to escalate concerns. The provider was aware of and understood their legal responsibilities around notifying CQC about any important events that had happened in the service.

The provider fostered a culture where people felt they could speak up and their voice would be heard.

People and relatives were happy to raise and share concerns. They were confident action would be taken.

There was a whistleblowing policy in place and staff were aware of this and the procedures they needed to follow. The home had created an open-door policy where staff were able to speak up and share their concerns, they felt assured action would be taken.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for the people who worked for them.

Staff told us they were happy working within the home and felt they were treated fairly. There were procedures in place to consider staffs’ individual needs and ensure all staff were treated equitably.

There were not always effective systems in place to make changes and identify areas of improvement.

There were audits in place which monitored the safety and quality of care, including people’s environments, management of medicines and any complaints that were received. There was also a system in place to monitor and review accidents and incidents that had occurred. However, the audits in place had not always identified all areas of improvement. The registered manager had identified in their service improvement plan in April 2026 that some records may need improving, they had identified this and were in the process of completing a full audit of people’s records. They had 5 people’s records remaining to audit. However, we could not be assured these audits were always effective as a completed audit had not identified there was no care plan in place for the person whose mobility needs had changed. In addition, due to this action, it meant the other monthly audits the team leaders were completing had not audited people’s records. This had been paused so the registered manager could complete their audits. This had therefore created a shortfall in other concerns being identified. We were therefore unable to ascertain when the last audit had been completed for the person who was not having Epilepsy checks in line with their plan. The registered manager told us it would have been around November 2025. This meant the systems in place did not always ensure people’s care was regularly reviewed.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

There were systems in place to ensure the provider worked in partnership with other agencies and professionals to ensure care was safely delivered to people. As part of this assessment, we asked health professionals for feedback who raised no concerns.

People had participated in ‘Learning disability week’ by taking part in a walk around the local park, they had a held coffee and cake event at the home after this, that members of the public were invited to attend. As the theme of Learning disability week was ‘do you see me’ the walk had be arranged to ensure people were seen and heard and to increase their community presence.

The provider did not always focus on continuous learning, innovation and improvement across the organisation.

The systems in place were not always effective and had not identified all concerns as reported upon, or driven all required improvements, which meant learning opportunities maybe missed. The registered manager had a service improvement plan in place which identified action that needed to be made to ensure learning and improvements were identified. However, this needed to be fully embedded throughout the home to ensure it was always effective.

The provider had not acted upon the recommendation we made at our last inspection to ensure people were involved with all aspects of their care, which meant right support, right care, right culture guidance was not always fully implemented. The recommendation from our last inspection had not been used to drive improvement throughout the home and make the necessary improvements needed.