Pilgrims Way Care Home with Nursing

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 requires improvement. 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 governance at the service and notifying CQC.

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 have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They were not effectively meeting the challenges and the needs of people and their communities.

There was clear division within the staff team as reflected by the feedback from staff in the staff survey. There was conflict within the staff team and a poor culture with staff raising concerns about rudeness and disrespect within the staff team towards other staff. The registered manager told us they were aware there was division. However, actions taken to address this had not been effective and there were still concerns.

The registered manager told us they and the management team spent time outside of their office and had an open-door policy. However, we found evidence there were areas of poor culture at the service which needed to be addressed. For example, one incident report showed a person had become deeply distressed when staff were discussing concerns with the person. The conversation should have been handled more sensitively. Staff then recorded that they’d have a conversation with the person’s relatives. The person had capacity and there was no discussion about if they wanted their relatives informed.

The provider did not have 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. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The registered manager told us they had made improvements to the service, which was previously rated by CQC as good. However, we did not find this was the case. Standards of care and safety had significantly decreased since the last inspection. As well as a downturn in standards, notifications, which legally needed to be submitted to CQC were not and safeguarding concerns were not raised with the local authority. We were not assured the registered manager had led the service effectively and our findings were poor. We found concerns across the service in how care was delivered to people and within the staff team. Managers had recently met and put together an action plan for the service to lead improvements. However, the registered manager had been in post for well over a year and had not addressed significant failings.

The registered manager had worked in care for a number of years. However, they had worked in community care and not in a care home. They also had no experience of leading a nursing service and was not a nurse. They were, however, supported by an experienced part time clinical lead who was a nurse. There was also a deputy manager who was new in post and had not had time to make any significant changes. We asked the registered manager about their background. They told us, “I know that I was going to be out of my depth in terms of nursing, but I can bring passion for care.”

People did not feel they could speak up and that their voice would be heard.

The service action plan for May 2026 stated the service had met the action to, ‘Create a culture where people feel safe to speak up, and ensure their voices influence practice and decisions.’ However, we did not find this culture was in place. Some staff fed back through the staff survey they did not feel able to raise concerns within the service. Some staff wrote about tension, disrespect and bullying within the staff culture. The survey was ongoing at the time of the inspection and therefore the registered manager had not had time to review all responses. However, they told us they knew there were divisions in the staff team and had taken limited action to identify and resolve concerns.

We raised this with the registered manager and asked if they knew there’d been accusations such as bullying within the staff team. The registered manager told us, “In supervisions staff are given the chance to talk about any concerns they may have…. they don’t always come forward with negatives; some wait until the survey. We are trying to get them away from that, don’t wait until the survey, if there’s something you want us to deal with.”

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.

We asked the registered manager how they supported and valued diversity in the workforce. They told us they sought support from human resources when there were issues in the staff team that involved diversity.

Prior to the inspection they told us the service had a diverse staff team and staff were supported with cultural celebrations and holidays.

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

Governance of the service was poor and needed significant improvement. There were systems in place to identify concerns, and some concerns had been identified. However sufficient action had not been undertaken to address these concerns, and service users remained at risk. For example, we reviewed the service action plan dated May 2026. This plan identified the service needed to carry out regular fire drills with staff. When we visited the service in August 2026 there were still concerns about staffs understanding of how to support service users in the event of a fire or use fire evacuation equipment. This safety concern had not been sufficiently prioritised and was not prioritised until inspectors raised concerns.

Audits and systems had not led to sufficient improvements being made at the service. For example, audits of medicines had not ensured there were risk assessments in place for emollients. Quality assurance systems had not led to bowel movement and constipation risks being reviewed and risks to service users being identified. Oversight of infection prevention and control had not been addressed. Environmental auditing failed to address safety concerns.

Statutory notifications had not been submitted to the CQC when they were required to be by law. We identified a number of incidents and safeguarding concerns which should have been reported to CQC and were not. The registered manager told us they were not clear on what should be reported. However, they had been a registered manager for a number of years prior to joining this service and should have had a clear understanding of the requirement as part of their role.

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

The service worked alongside a number of health and social care partners and most of these partnerships worked well in the majority. However, they had failed to ensure safeguarding concerns were reported to the local authority in a timely manner to ensure service users were protected from the risk of abuse. The local authority has the primary responsibility for safeguarding adults. This meant the local authority had not had the opportunity to triage and/or assess and mitigate risks to people.

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.

The registered manager has been responsive to the concerns raised during the inspection and some actions have been taken to address concerns. We have also received an action plan setting out how the service is going to address shortfalls and ensure people are safe. Some actions were completed immediately after the inspection to start to address concerns. However, actions should have been prioritised and taken prior to CQC identifying concerns.