Blythe Rose Care Home Also known as 1-12948766437

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 good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (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 demonstrate a clear and fully shared vision, strategy and culture across all levels of the organisation. While values were intended to be based on transparency, equity, equality, human rights, diversity and inclusion, these were not consistently embedded or aligned between service‑level leadership and the wider provider.

While staff and the registered manager appeared aligned in their priorities, this did not consistently align with the wider provider’s expectations. The registered manager acknowledged challenges to comply with corporate processes and frequent changes in senior leadership, which had led to shifting priorities and different visions over time. This created challenges in achieving consistent alignment between service‑level leadership and the provider’s wider strategy.

However, staff consistently described a positive culture within the home and said the registered manager had provided strong direction and driven improvement. Staff told us that the culture in the home was, “Nice”, Supportive” and “Everyone regardless of their backgrounds, shared the same values of care”. One professional commented, “The home wouldn’t be where it is today without [the registered manager],” and staff shared “[the registered manager] really understood the needs of the service.” The registered manager described clear values focused on compassion, honesty and psychological safety, explaining teams faced and worked through challenges together.

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. They did so with integrity, openness and honesty.

A relative told us, “I could tell from my conversation with the manager they have a commitment and passion to support people with dementia,” while staff described feeling, “Supported” and “Listened to”. One staff member explained that the registered manager was different from previous leaders stating, “[the registered manager] had ensured access to specialist training.” Another staff member shared, “The manager has done really well. They have reorganised the home to make it better for all those that live and work there. [The manager] recognises everyone is different and has different needs”. Staff felt encouraged to develop, with leaders promoting opportunities for progression and additional responsibilities. Professionals described leadership as open and transparent. The registered manager had extensive experience and demonstrated strong knowledge of dementia care, Crisis Prevention Intervention (CPI), safety and workforce development, supported by ongoing training and professional networks.

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

Staff described an “Open” and “Approachable” culture, supported by visible leadership and an open‑door policy. The manager explained they made time to listen, encouraged ideas and gave recognition where improvements were suggested. Staff told us they felt comfortable raising concerns and saw actions taken as a result, including the introduction of additional training following discussions about restraint and staff safety. One staff member said, “[The manager] listens to concerns and makes sure actions are implemented where needed,” and another confirmed they felt confident to raise concerns if required. Whistleblowing processes were understood, with confidentiality emphasised and concerns investigated appropriately. However, one staff member reported that they had raised a concern and did not feel change had happened. On review, we saw actions were underway, though progress was dependent on engagement with multiple stakeholders, which meant changes could not be implemented immediately.

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.

Most staff had completed equality and diversity training, and demonstrated awareness. Staff told us the service was flexible and supportive, with one commenting, “Everyone is very attentive at all times and flexible as an employer to meet staff needs.” Leaders described transparent recruitment and promotion processes based on merit, with mixed interview panels and clear scoring to support fairness. The provider made reasonable workplace adjustments to support staff wellbeing, including phased returns to work, additional breaks and changes to shift patterns to meet individual needs. Managers led by example by taking time to understand staff circumstances and promoting open communication. Staff were supported during significant life events, and adjustments were made to help them remain in work where possible.

The provider did not always have effective governance systems to identify and manage risk consistently.

Some routine checks had not identified issues we found on assessment. For example, some audits were incomplete or not signed off by the registered manager. We also saw occasional inaccuracies in medicine records. For example, where the code “other” was used instead of “refused” when administering medication. There had been under‑reporting of statutory notifications. The manager explained there had been confusion about reporting thresholds between agencies; this was discussed during assessment and has since been clarified to support future compliance.

However, there were strong governance foundations in place. The registered manager and deputies demonstrated good oversight, integrity and understanding of care delivery. Systems were in place to analyse care records, incidents, and peoples’ responses which were reviewed through weekly multidisciplinary meetings and detailed monthly overview reports. A comprehensive audit programme was in place, supported by provider oversight, external audits and action plans.

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 service actively collaborated with health and community partners, including working with an NHS specialist palliative care team to strengthen end‑of‑life pathways. Links were established with voluntary organisations such as the Alzheimer’s Society, Dementia UK and Age UK, and the home provided space for a family support group, helping families feel supported and promoting a sense of togetherness. The provider opened the home to local agencies, including neighbourhood teams and social workers, who at times used the service as a base for meetings. The home also supported the wider community by working with a local food bank and hosting awareness events. The manager described efforts to challenge misconceptions by engaging with neighbourhood teams and increasing understanding of dementia. Schools were invited to take part in seasonal activities, such as singing at Christmas. While some opportunities were limited due to safety considerations, the provider continued to explore ways to strengthen community links and raise awareness.

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 service used information effectively to monitor performance, with regular reviews of accidents, incidents, falls and distressed behaviours. Trends were analysed over time and compared with previous months to identify learning and inform actions, supporting safer and more effective care. Clear policies were in place to guide staff practice and learning. The provider encouraged professional development and recognised good practice, with staff being nominated for awards related to developing others. Leaders described aspirations to adopt recognised quality frameworks and to build stronger links with external learning opportunities in the future. A health professional told us, “The home’s culture is of continuous learning and improvement,” and highlighted the home’s ambitions to support student placements and research activity in the future.