St Anselm's Nursing 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 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 good governance.

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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. The leadership team were based in a building in the grounds of the service and whilst they did spend time in the service, they did not have consistent oversight on staff practice which impacted on the standards of care provided. Whilst some staff told us they could go and speak to managers when they needed to other staff told us they would like to see managers more. For example, we raised concerns with the providers regarding cleaning equipment being left unattended. They told us this was an ongoing issue. We identified times where staff were not as patient with people as they needed to be. This was also an issue the providers were previously aware of. However, cultural direction and supervision had not led to this being improved.

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.

The day-to-day management of the service needed to be improved. The new manager had undertaken a qualification in health and social care. However, they did not have direct experience as a registered manager and needed more support during their learning journey. The new managers previous role of office manager had also not been replaced, and they had a significant workload. Immediately following the inspection the previous registered manager, who worked at the service as a nurse, was asked to provide the new manager with support and spend time in the office updating care plans and undertaking clinical oversight. Whilst the providers and management were transparent during the inspection and open to our findings, they needed to have identified and addressed issues prior to the inspection being undertaken and had not. This raised concerns about how effective management would be going forward.

Staff told us they could speak to management and raise concerns. However, mechanisms to encourage structured staff feedback were not always in place to ensure staff were encouraged to speak up and that their voice would be heard. Staff meetings were not being held at the time of the inspection. There had been meetings for staff in August and September 2025 but no meetings since. There had been a survey for staff in April 2025, but staff response was limited with only four staff having responded. Two out of the four people having responded raised concerns over staff teamwork, and during the inspection some staff told us communication between staff teams still needed to be improved. We also identified other concerns which were echoed by some staff such as how some staff acted in front of people.

Whilst staff told us they could raise concerns we identified significant concerns at the service which had not be raised by staff. For example, incidents which were not reported.

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. The providers respected and valued diversity in their staff team and provided support to staff with equality needs to ensure staff were supported and included. For example, there was a quiet space where people could pray if they wanted to do so. Staff told us they felt valued. One staff said, “I do feel the management value the staff, they do realise we work hard. We could all learn from each other.”

The provider did not have clear responsibilities, roles, 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 needed significant improvement to ensure people were well supported. Auditing had not always identified concerns or ensured concerns were addressed. For example, audits of people’s bowel movements had been undertaken. However, these had not identified people were being supported with medication, which was effective, but their charts were not updated. There was no review of people’s fluid intake, how often people were repositioned. Whilst the provider was aware there were concerns regarding medicines management staff competency assessments had not been completed to check on staff practice.

Records were poor and there were gaps in recording which reduced the providers ability to effectively monitor care. For example, there were gaps in people’s continence records to show how often people were provided with this support. Care plans needed to be updated. For example, one person’s care plans stated they needed 1 to 1 support during all waking hours. The provider told us this was no longer the case, and the person only needed this support when they were upset.

The provider did not always inform CQC of notifiable events. Some safeguarding incidents had occurred, and a notification was not sent. It is a legal requirement CQC is notified, and this was not done.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. However, some partners did raise concerns where improvement was needed. People were referred for services where they needed support from other agencies. Staff had worked on ensuring people were referred quickly where they needed support and feedback was that people were. However, partners did raise concerns relating to areas of concern we found on inspection such as how risks were managed and the inconsistency relating to staffs approach.

The provider did not 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 actively contribute to safe, effective practice and research.

There was a lack of evidence staff undertook reflective practice after incidents occurred where restraint was used. For example, were no records of de-briefing or reviews to check the action taken was appropriate and explore if there were other options which could have been taken which were less restrictive.