Inglefield Nursing & Residential 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 remained 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. While leaders were supportive and committed to improvement, governance systems were not always effective. Shortfalls in oversight of risk management, medicines, consent, monitoring tools, care planning, and learning from incidents reduced assurance that quality and safety were consistently managed and sustained.

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 clear shared vision, strategy, and culture centred on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding the needs of people and their communities.

Staff demonstrated understanding of and commitment to the service’s mission, values, and statement of purpose, and could articulate how these guided their day-to-day work. They also emphasised the importance of team support and building strong relationships with people.

Staff feedback highlighted a positive, people-focused culture. A member of staff said, “Our residents don’t live in our work, we work in their home,” while another staff member commented, “Working as a team and treating the residents as our own family members is a virtue here.” Company values were prominently displayed throughout the service, reinforcing a shared commitment to high-quality, person-centred care.

Governance and communication structures supported this culture. Quarterly compliance meetings with heads of departments provided opportunities to review performance, identify areas for improvement, and align operational practice with strategic goals. Inductions, supervisions, and regular team meetings reinforced shared expectations, supported consistent care delivery, and strengthened team structure.

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 and acted with integrity, openness, and honesty.

Leaders maintained oversight and competence. Managers had regular supervisions, competency checks, and all required e-learning and training, keeping their knowledge of roles and responsibilities up to date. They demonstrated a clear understanding of legal frameworks and regulatory requirements and had already identified areas for improvement, progressing these through an active service improvement plan.

People and relatives recognised effective leadership. One person told us, “The manager is very good… she listens and does something about it,” and another person commented, “I adore the manager.” Relatives noted, “I often see the manager there… sat talking with my relative,” and, “The manager has been beyond helpful.”

Staff described leaders as approachable, supportive, and compassionate. Feedback highlighted that managers listened, provided guidance, and responded promptly to concerns. Comments included, “They always listen and take the time to support us,” and, “Management is supportive, approachable, and professional.” These leadership qualities contributed to a positive, inclusive culture where staff felt valued, motivated, and confident in their roles.

The provider fostered a positive culture where people felt able to speak up and raise concerns, confident their voices would be heard and acted upon.

Staff reported they could raise worries without fear of reprisal and that managers responded promptly and appropriately. Staff felt able to contribute ideas, make complaints, or escalate issues, knowing these would be handled professionally and transparently. One staff member said, “Staff feel comfortable to speak and support each other,” while another commented, “Yes, I do feel I have a voice.”

Policies and guidance reinforced openness. Up-to-date whistleblowing policies were in place and accessible to all staff, supporting transparency and accountability. Staff confirmed they understood how to follow these policies if required.

Feedback from people, relatives, and staff reflected this positive culture. A person told us, “Anything I’ve got worrying me I can say something,” and a relative noted, “I can approach the manager there about anything.”

The service promoted a culture of empowerment and safety, ensuring that staff and people felt supported to raise concerns, contribute ideas, and participate in decision-making, which helped maintain effective, safe, and person-centred care.

The provider demonstrated a strong commitment to equality, diversity, and inclusion within their workforce, fostering a fair, inclusive, and empowering culture. Policies and processes reflected best practice and complied with legal frameworks, including the Equality Act 2010, ensuring that all staff were treated equitably and supported to deliver high-quality care.

Diversity was actively celebrated and promoted by all. An Equality and Diversity board displayed in reception highlighted different cultural themes each month. For January 2026, this focused on Zimbabwean culture and gastronomy, which helped to enhance cultural awareness and understanding among all people using the service.

A person told us, “Overseas staff work well with the others, very good and very kind.” Another person observed: “I really like to read the cultural board downstairs. It gives me better insight of staff’s cultural backgrounds and helps me understand them better.”

Staff told us they were supported through reasonable adjustments to meet a range of needs, including religious observance, childcare responsibilities, disability, family connections, and health protection requirements during infectious outbreaks. A member of staff told us, “I have never felt this supported by an employer. They truly see us for who we are as people with different strengths, cultures and backgrounds. It’s nice to feel that we are not just a number”.

Resources and guidance were accessible to all staff in various languages. Staff booklets provided clear information on different areas of care such as accidents and incidents, personal care and safeguarding, and materials were available in multiple languages including Hindi and Romanian, supporting an inclusive approach for the diverse workforce.

Staff reported feeling respected, valued, and empowered to contribute fully, which enabled them to provide equitable, compassionate, and high-quality care. The provider’s approach actively supported both workforce engagement and positive outcomes for people using the service.

The provider’s governance and management systems were not effective at identifying shortfalls in aspects of the environment, medicines management, and care planning. While leaders had systems in place which had enabled them to identify a small number of improvement actions, governance processes failed to identify or address a range of concerns we identified across the service.

The provider did not always manage risks to people’s safety effectively. Environmental and risk management audits did not consistently identify hazards or ensure timely action. As a result, potential risks were not always identified and mitigated, limiting assurance that the service was safe and well monitored.

The provider did not always ensure effective oversight of care delivery and people’s rights. Systems had failed to identify that consent processes were inconsistent, with unclear or illegible documentation, and the use of CCTV lacked explicit consent. Monitoring tools, including NEWS2 and pain assessments, were completed, but lack of oversight meant mangers had not identified where staff had not acted on results. Indications of ill-health and pain assessments were not always followed up, meaning people’s needs were not consistently responded to. Care records were not maintained to ensure they were accurate and up to date.

The provider’s governance systems did not always ensure safe and effective medicines management or accurate care planning. Managers did not identify concerns relating to medicines storage, fridge temperature monitoring, or the use of medicines beyond in-use dates. PRN protocols were not consistently personalised, and some care records contained inaccuracies or contradictory information, which governance processes failed to detect or correct. Leaders were visible and supportive, and staff engaged with training and improvement activity. However, governance oversight did not ensure that risks, audit findings, or improvement actions were consistently monitored or embedded into practice. Although individual concerns did not always present a significant risk, the cumulative impact of these failures resulted in widespread concerns and did not support safe, effective, or sustainable care consistently.

The provider demonstrated a strong commitment to partnership working and community engagement, ensuring that care was coordinated and responsive to people’s needs. Staff understood their duty to collaborate and worked proactively with external partners to support people’s health, wellbeing, and social participation.

Healthcare collaboration was structured and effective. Weekly ward rounds and reviews for Funded Nursing Care (FNC) and Continuing Healthcare (CHC) ensured people’s health needs were regularly assessed and addressed. Multi-disciplinary team (MDT) meetings facilitated joint decision-making with external professionals, supporting coordinated, person-centred care.

Community links enriched people’s experiences and promoted social inclusion. Activities included local dementia choirs, intergenerational visits from nurseries, arts and crafts, gardening, and a pen-pal scheme with other care homes. These initiatives supported social interaction, meaningful engagement, and improved wellbeing.

Feedback from professionals and people was positive. Healthcare staff praised the service’s responsiveness and support for people with complex needs, while people and relatives highlighted the uplifting impact of community activities and partnership work.

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.

Systems to support improvement were in place, including a service improvement plan and digital auditing tools. However, these were not always used effectively to drive sustained, measurable improvement. Action plans did not consistently provide clear or specific steps, and follow‑up was not always evident, limiting assurance that learning informed meaningful change.

Opportunities to share learning across the team were not always maximised. While staff accessed training and external learning opportunities, documentation of reflective discussions, debriefs or learning outcomes was not always consistent. This reduced the service’s ability to demonstrate how new knowledge had influenced practice or contributed to wider service development.

Despite these shortfalls, staff were positive about developing their skills and felt supported by managers. The provider acknowledged the need to strengthen arrangements for learning and improvement and had begun reviewing systems to ensure changes were better planned, monitored and embedded. These improvements were at an early stage and not yet consistently applied across the service.