The Wells 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 requires improvement. 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.

We found a breach of Regulation 17, Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Governance systems and audits to monitor the quality of the service were not effective.

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.

People told us they were happy living in the service and were complimentary of the staff team and management.Comments included, “(Registered manager) is exceptional, staff are kind, food is very food, activities are very good.” One person told us about a recent bereavement and how kind and reassuring staff were and added that the registered manager, “Came and held my hand and comforted me.” A relative told us, “(registered manager) is absolutely super, she thinks about his needs and speaks to me, she is empathetic.”

We observed lots of caring interactions between people and staff throughout the day and staff remained patient.

The provider had inclusive leaders at all levels. However, the provider did not demonstrate effective leadership or robust quality assurance in their oversight of the quality and safety of care. The provider had not recognised the deficiencies within their own service and that their systems and processes were not identifying areas of concern or areas for improvement.

Despite this, people and relatives felt confident in the registered manager and management team.Comments included, “I have no concerns or issues, (named 2 nurses) are good, as is (registered manager) the Manager”; “The Manager is very nice, I would go to her if I had a concern or issue” and “(Registered manager) communicates well with my family.”

The registered manager was responsive to our feedback and along with the general manager was dedicated to addressing deficiencies and improving the service.

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

The registered manager held monthly coffee mornings, so they could speak with people and their relatives to ask for their views. They were also very active within the home and spoke to people most days. A relative told us, “We have given feedback by a questionnaire this year, they have resident’s meetings which she attends. The manager is (registered managers name), I can talk to her, and (named nurses). I can speak to any of them, they all ask how I am doing.”

Staff felt able to raise concerns and were confident they would be listened to.Staff told us there were team meetings or group supervision sessions and handovers so things could be discussed there.

An agency staff member told us, they liked working at the home, had felt welcomed, and felt if they had a concern, they would be happy to raise it with the senior team.

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.

There were staff from a range of backgrounds working in the service. Staff told us they felt treated fairly at work and were supported in their role, through meetings and supervisions. The registered manager recognised the importance of staff inclusion and teamwork. They told us about how they had lots of theme days at the home and arranged treats for staff, for example ordered pizzas.

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.

We found, oversight of the quality monitoring within the home had not been effectively managed and carried out. On the first day of our assessment, we identified environmental concerns. We found the oversight monitoring of the environment was not robust and placed people at risk of harm. For example, the provider had a maintenance records check book which required checks to be completed. In 2025, not all these checks had been completed. For example, wheelchair monthly visual checks and electric bed monthly checks had not been completed in 2025. Audits had been completed but had not identified areas which required improvement.

Action was taken by the provider during the assessment process to resolve environmental issues identified. New monitoring processes were put into place, with an improvement provider oversight of existing processes to ensure they were being completed. The provider also put in place a service improvement plan, setting out the areas for improvement required and the actions being taken. Although these actions had been taken, they need to be embedded to see if they are effective and identify areas for improvement.

The provider’s representative undertakes monthly visits and completed quality monitoring checks. However, they had not identified all the concerns we found.

The provider did not always submit required statutory notifications, promptly to CQC. We discussed with the registered manager the need to delegate this responsibility to senior staff when they were on leave.

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 shared examples of engagement with the GP surgery which supported the home and other healthcare professionals, showing they were willing to engage with partners to review whether processes were working.

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 and providers general manager took prompt action to address concerns as they were identified by us during the assessment process. We found the provider’s quality monitoring processes were not always effective. The introduction of the providers service improvement plan gave us assurances that risks and systems were being addressed. The general manager also gave us assurances that lessons learnt from this assessment would be implemented in the providers other services.