Strode Park 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 good. 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 service was in breach of legal regulation in relation to the governance and oversight of the service.

This service scored 36 (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 have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. There was no clear shared culture within the service. Following our last inspection the previous registered manager had worked with staff to develop a shared culture within the workforce. However, the workforce had changed, and the work had not continued. The management team did not include discussions around the vision, direction and culture at staff meetings, to develop a sense of ownership.

The various job roles and responsibilities did not promote an inclusive culture within the service. Staff told us there was confusion at times about who was responsible for different tasks and handovers between roles were completed separately. Staff did not receive a holistic view of people’s care and feel involved in all aspects.

The provider had a yearly awards ceremony, where the staff council voted for staff from all the provider's services, in different categories. These awards were given to staff who had displayed the values of the provider, some staff from Strode Park House had been included.

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. At the time of our inspection there was no registered manager in post. The current manager had been in post since February 2025, they told us they had started their registration with CQC but had not fully understood the process which had caused a delay.

Staff did not always feel supported by the management team, concerns had been raised about the lack of onsite support at evenings and weekends. There was a provider on call system where managers from the provider’s other services were available. However, staff did not always feel it was appropriate to contact them when concerns were specific to the service.

The nursing staff had raised concerns, during staff meetings, about the way errors had been dealt with. They had not felt supported when medicine errors had been identified. The management team had decided to issue letters of concern to all nursing staff but had not given them the opportunity to discuss the concerns and identify how to reduce the risk of them happening again.

Staff did not always feel comfortable to speak up about incidents involving people. Some staff had been subjected to racism from people, they had not felt comfortable to raise it and were accepting it. However, the management team have now addressed these concerns with people and the incidents had stopped.

Staff attended staff meetings where issues and concerns were discussed, however, when they have spoken up they had not always been listened to. For example, when nursing staff raised concerns about the way medicines errors had been dealt with, the management team had not acknowledged their concerns about the process. Staff told us this had impacted on their wellbeing and the medicines errors had continued.

Staff had not received regular supervision to discuss and raise concerns they may have, and they had not been given opportunities to make improvements or develop skills. People had completed a survey in December 2024, but this was while the previous registered manager was in post. There had not been any checks to make sure people were still happy with the service they were receiving. Staff surveys had not been used to identify if there were concerns and how improvements could be made.

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. The manager told us they supported staff and were flexible, giving the example, of staff not working on a Sunday so they could go to church. They described how they worked with staff when they asked for rota changes. We discussed with the manager, their role in identifying staff protected characteristics, to offer them support.

Staff told us they had not been given the opportunity to share their culture with people and other staff. There had been attempts to cook food from different cultures. However, this had not been successful, as relevant staff had not been included.

Staff told us they had been welcomed by staff and had not been discriminated against.

The provider did not have clear responsibilities, roles, systems of accountability and good governance processes in place. There were no effective systems to monitor the quality of the service and drive improvement. The organisation of the service and staff responsibilities in providing care and support were complex. The role of the clinical lead and nursing staff was not clear. The clinical lead did not complete competencies, audits and checks linked to clinical tasks. The nursing staff delegated their tasks to other staff, however, the clinical lead or nurses were not responsible for checking care staff were competent to complete the tasks allocated. The assessment of staff competence was completed by the deputy manager but there was no evidence to show they had been assessed as competent by the clinical lead to complete this role. Nurses did not have responsibility to write care plans and risk assessments around people’s clinical needs. The leadership during a shift was complex with lead carers in charge of organising the care staff, senior care staff or nurses administering medicines and a nurse or nurse associate completing clinical tasks. Staff told us there were too many layers and things could be missed, there was no role which had oversight of all aspects of people’s care including when to refer people to health professionals. The management team had not supported nurses to provide clinical support and meet their responsibilities under delegated tasks in their code of conduct.

The manager had identified auditing needed to be improved in February 2025, but an effective system had not been put in place at the time of the inspection. There had been some checks completed but these had not been comprehensive and when shortfalls had been identified, there were no action plans to rectify the shortfalls. Audits had been completed by a consultant in August 2024 and January 2025, however, there had been no provider audits since the management team had been in post.

There was limited oversight of night staff, the management team did not see night staff routinely due to their working hours. There had been one night spot check completed since the new management team had been in post. The provider could not be assured of the quality of care being provided at night. Staff had raised concerns about the lack of night support, the provider had not acted on these concerns to ensure night felt supported in their role.

The management team had not identified the shortfalls found at this inspection. They had not always understood the processes which needed to be followed to make sure people were supported in the least restrictive way and received safe care and treatment.

The provider did not always understand their duty to collaborate and work in partnership with other agencies or services, in order for services to work seamlessly for people. There had been concerns raised by healthcare professionals before the inspection about the skills of staff and they had not been comfortable to raise the concerns with the service. The professionals had raised safeguarding concerns with the local authority who then contacted the service. Following these concerns the management team had started to work with professionals to improve the relationship.

The service had not ensured district nurses had attended to the nursing needs of the people assessed as needing residential care as required, this was being rectified following our inspection.

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. The quality of the service had deteriorated since our last inspection. The provider had failed to learn and improve, there continued to be shortfalls with medicine management, which had been identified at the previous 3 inspections.