121 Watleys End Road

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 good governance at the service.

This service scored 62 (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 understanding challenges and the needs of people and their communities.

The team had recently completed a team building day where they had clearly discussed the vision of the service, inclusion and engagement. Views were sought from staff which helped them develop an action plan. From talking with the management team and staff, this had been productive and many of the actions were being implemented and worked towards. This included building on team communication and making improvements for people living in the home such as introducing more activities in the home and the community. A member of staff told us, “I feel that communication has improved, and the things that are being put in place should see an improvement in thelives of the people we support.

Staff were committed to providing care that was tailored to the individuals within the resources they had. The culture of the service was observed to be inclusive, and staff were committed to providing care that met the needs of the people living in the home.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The management team were visible, knowledgeable and supportive. Both the registered manager and the deputy manager worked alongside staff to help them develop their roles and support people. The management team were open and transparent acknowledging the journey the home had been on over the last 12 months, which had impacted on staff morale, the culture of the service and communication.

The provider’s quality team visited the service to meet with people, staff and complete checks on the home ensuring ongoing compliance. The operations manager was a frequent visitor to the service supporting the registered manager and the staff team alongside their responsibility to complete checks on compliance to the action plans that were in place.

The provider was rolling out leadership training, and both the registered manager and deputy were in the process of completing this.

The registered manager attended monthly management meetings where learning and risks were discussed across the whole organisation.

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

Staff felt the culture now enabled them to speak up. Staff felt confident their voice would be heard and the management team would address concerns. Staff said they would have no hesitation in speaking up whether that was to the management team or the provider.

The service had policies and procedures for staff to follow should they wish to speak with external agencies. This included the local authority, CQC or the police in respect of concerns and allegations of abuse.

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. Policies were in place to protect and promote the rights of the people using the service and the staff team. Staff had completed equality and diversity training. The service employed a diverse range of staff.

Staff were positive about how the team worked together to support people living in the home.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The governance arrangements at the home were not effective in identifying the shortfalls we found as part of this assessment. For example, internal audits had not identified improvements were needed with people’s care plans and risk assessments that were not up to date or were missing information.

The audits had not identified staff had not completed a fire drill and the monthly health and safety checks on the equipment had not been completed. There was no infection control audit completed in the last 12 months in line with the provider’s policy. Although this had been an action from the provider’s own quality team back in the Summer of 2025 and the provider’s expectation that this should be completed annually. Whilst medicine audits were completed weekly, checks to ensure medicines were within date and clearly labelled with dates when tropical creams were opened was not robust.

A new dashboard had been introduced to capture training. However, compliance for each member of staff was difficult to interpret as not all staff required the training such as kitchen and housekeeping staff. This meant the overall compliance figures for the service was not correct. Some staff had achieved only 50% compliance. However, when checked some staff had completed an equivalent training or a higher level such as safeguarding for managers and this data had not pulled through to increase their compliance to the training statistics. This was fed back to the registered manager who acknowledged the data could be misleading.

The registered manager did not check staff received regular supervision in line with the provider’s expectations.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The registered manager and staff worked closely with various health and social care professionals to help enhance people’s life and wellbeing. This ensured continuity of care and improved systems and processes.

People were supported to maintain contact with people who were important to them. Relatives confirmed they could visit their loved ones and were involved in their care.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The registered manager was open and transparent about the journey the service had been on over the last 12 months. This included introducing a new electronic care planning system and a new medication system. It was evident this had impacted on the staff morale along with a number of long serving staff leaving with agency usage increasing. The management team had been proactive and engaged with staff to develop an action plan to make improvements to the service and improve outcomes for people living in the home. This was being embedded into the service. Staff were aware of the action plan and clearly described the improvements that were taking place.

The provider audited different areas of the service based on the key questions of safe, effective, caring, responsive and well led. When concerns were identified, action plans were put in place and monitored by the operations manager. However, these were not always effective as described previously.