Thames 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 inspection we rated this key question good. At this inspection 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 had a shared vision, strategy and culture. This was based on transparency,equity, equality and human rights, diversity and inclusion, engagement, and understandingchallenges and the needs of people and their communities.

The provider had a clear statement of purpose and vision and strategy for the service which the leaders were aware of. Values were important to the leaders we spoke with, and they told us they were incorporated into everyday processes within the service including when nominating someone for employee of the month or when being interviewed for a position.

Some of the individual staff supervisions we reviewed, revealed frictions between staff members and we observed a minor dispute between 2 members of staff on our second inspection day. The supervision documentation indicated certain staff felt others were not doing enough work and had a preference to work on a certain floor as the people had fewer complex needs.

Leaders told us there were some existing cultural problems within the workforce which they were trying to address. Prior to the inspection, we had received multiple concerns from staff regarding safety and the overall culture of the service; leaders had held a listening event between 14 and 18 January 2025 in which they arranged to meet with any staff who wished to do so. They ran the event for a week to allow staff the opportunity to discuss any concerns or issues they had so they could be resolved.

Staff told us the culture had improved since the manager had come into post.

The provider had inclusive leaders at all levels who understood the context in which they delivered care. Leaders had the skills, knowledge and experience to lead effectively, however they had not identified all the concerns we found during this inspection.

At the time of this inspection, there was no registered manager in post. The manager, who had stepped into the role when the previous registered manager left, had been in post for approximately 8 months and had submitted an application to register. This application was granted during the course of this inspection.

Leaders felt adequately supported by their seniors and had access to inductions when they first started.

Staff told us the manager was always available and regularly visited the service when not on official duty. One staff member told us, “[Manager and clinical nurse manager names] have offered open sessions for staff to come in and talk about any concerns. They have spent time trying to get the culture right and we are still not quite sure why some staff are negative.” A second staff member said, [Manager name] does listen to staff, but there are some who are deliberately causing problems, such as not turning up to shift handovers and not wearing uniforms.”

Although relatives had mixed opinions about the quality of communication, several relatives commented positively on how the service was managed. One relative told us, “I would speak to a nurse if there were problems then she would tell the manager.” A second relative said, “I would speak to the manager then head office about any problems.” Staff and leaders respected people’s preferences with regards to choices of colour for bedroom décor and soft furnishings.

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

Leaders sought the views of people and staff, to drive improvement and encouraged staff to raise concerns. A staff survey, completed in February 2025, had resulted in an 88% staff response rate. Leaders had discussed the contents of staff feedback and used this to develop actions moving forward, for example, a ‘You said we did’ board had been re purposed and was now reviewed on a monthly basis.A final action plan based on feedback received was being developed for mid-April 2025; this included action around what leaders could do to make staff feel like their voice is heard and opinions shared.

There were mechanisms in place for staff to speak up and a culture to encourage them to do so through team meetings and formal 1:1 sessions which ensured staff had regular opportunities to engage with senior leaders. We saw evidence ‘whistleblowing’ had been discussed as part of the nurses meeting held on 30 January 2025. Nurses were reminded of the need to be available to manage concerns related to their floor and escalate concerns if required.

Staff were aware of the term ‘freedom to speak up’ and felt they would feel comfortable raising concerns if they needed to. Staff had access to the ‘raising concerns policy,’ last reviewed in November 2024, and other information which enabled them to raise concerns externally if required.

The manager embraced whistleblowing concerns and wanting to learn from them. They explained how positives had come from the concerns raised as they felt the service had taken a thoughtful approach in trying to understand the key issues and attempting to take appropriate action to resolve them.

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. Leaders provided flexible working agreements to staff to account for personal circumstances such as caring responsibilities and health issue.

The provider had staff champions in place, including a staff champion for equality and diversity. There was an up to date ‘equality, diversity and inclusion policy’ in place. We looked at the results of the staff survey completed in 2024, with 87% of the staff team responding. The biggest area for improvement was regarding regular staff meetings, where 25% of responses indicated the need for more meetings and 93% of staff who responded felt their job gave them a sense of purpose and achievement.

Leaders took steps to ensure staff were representative of the population of people living at the service. Leaders put reasonable adjustments in place for staff to help them carry out their role. Staff told us they were treated equally by leaders and gave examples of how the provider had supported them with flexible working arrangements when they had requested them. A staff member told us, “This is the best place I have worked at; the managers allowed me to work flexibly around my childcare needs.”

Managers engaged with staff via appropriate forums such as supervision and staff surveys, to ensure their voices were heard. Most staff were confident they could raise concerns directly with their leaders, and had received training in equality, diversity and human rights. However, some relatives had concerns about staffing. One relative told us, “They [staff] are nice people, but English isn’t always their first language. It seems to me that there is a massive turnover of staff.” A second relative said, “The staff are coming and going; there’s no continuity.” While some people's relatives expressed, they were unhappy with staff, our inspection found staffing arrangements were meeting the expected standards and staff were treated fairly and with equity.

The providers’ systems and processes had not identified all the concerns we found during this inspection. However, the provider had clear responsibilities, roles and systems of accountability in place.

We found there was a system of regular checks, monitoring and oversight from the manager and provider. However, systems in place and staff had not identified some of the concerns we found. For example, regarding accuracy of records, care plans and risk assessments, which were not always accurate or sufficiently detailed. Provider policies were not always renewed in a timely manner, activities were not always tailored to meet peoples’ needs and goals, palliative care required improvement and people’s relatives told us they were not always involved in helping to shape the service. Providers must have reliable systems and processes to identify quality and safety concerns.

Staff told us they felt the service was well organised and were aware of their roles and responsibilities. They could access all required policies and procedures.

Managers held regular meetings with staff, during which they discussed any concerns and emerging risks. Managers recorded any actions arising from these meetings and ensured they shared these with staff.

The provider had a business continuity plan, dated May 2024, which covered the relevant areas.

Audits were completed regularly, and outcomes were reviewed and acted upon by leaders.

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

The provider completed a ‘service user and relatives survey’ in 2024. Although 80% of relatives outlined getting enough communication from the service, most of the relatives we spoke with did not feel communication between the provider and themselves was consistently positive. One person said, “Getting information out of them is like pulling teeth.” None of the relatives we spoke with knew anything about any networking the provider completed with the local community. Within a listening session in November 2024, the provider acknowledged communication with family members required some improvement. The service had ensured each person using the service had a Key Worker in place and had encouraged them to engage with family members more frequently.

The provider documented feedback, including meetings and meaningful engagements with staff and people. Meetings for people were held every 3 months. We saw evidence of meetings for people from October and November 2024 and January 2025. Eight people attended the most recent meeting.

The provider worked with local partners to deliver better care and treatment. We saw regular contact with the local authority and integrated care board (ICB). For example, the ICB had completed a quality assurance visit on 4 December 2024 in which the overall impression was the service was well led and demonstrated a person-centred approach around the delivery of care.

Two people were identified as service ambassadors and attended meetings with other service ambassadors, support staff and directors from across different services run by the provider. We saw service user council meeting notes from the last engagement in which both ambassadors from Thames House were present and shared their views on the service.

The provider actively engaged with the local community, for example we saw in February 2025 staff, relatives and neighbours had collected toiletries and food for the local food bank. The provider had also invited the local authority to observe a themed event which they attended.

The local community supported the service, for example a local company had donated 4 wooden planters for the service and had plans to donate more in future.

There were no restrictions on visiting times for relatives, and leaders told us they were available to speak to if required. Staff supported this by telling us there were consistent and positive relationships between relatives, staff and leaders.

The provider used a quality assurance system which enabled them to monitor the standards of the service and inform organisational learning and improvement. However, we found some issues during the inspection which had not been identified by these systems.

The provider involved specialists and advisors in the monitoring and continual improvement of the service, including the local authority. The provider was transparent regarding the results of audits, inspections and assessments; however, we did not see actions from the most recent local authority visit on the action plan which was provided.

Staff told us they felt involved in the continuous improvement of the service. They told us they felt listened to by leaders when they raised ideas and suggestions.