Archived: Purbeck House Care 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

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.

This is the first assessment for this service. This key question has been rated 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.

At this assessment we reviewed all the quality statements for this key question. We found the service was in breach of legal regulation in relation to the governance of the service and the failure to notify CQC and partners of significant events.

This service scored 32 (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 failed to have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They failed to understand the challenges and the needs of people and their communities.

The provider failed to promote a clear vision, strategy and culture for the service which empowered people and enabled them to make decisions about their own care. Opportunities were not provided to people, relatives and staff to give feedback, and leaders were unable to demonstrate the feedback received was considered to make effective improvements in care provision and the overall running of the service.

We requested the minutes of the last 3 staff meetings. However, the management failed to provide this information. Therefore, the provider could not be assured that they had a clear and transparent approach that was shared with staff to support their learning.

Although we found some relevant policies were in place, these were not always up to date. Additionally, there was no effective systems to demonstrate staff had read and understood the policies or that these had been embedded in practice.

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

We identified multiple breaches of the legal regulations and significant concerns in areas including but not limited to, safe care and treatment, including the management of risks and medicines, safeguarding, consent, staff knowledge, skills and training and person-centred care. The provider had not independently identified and acted on these concerns prior to our assessment.

Although we found the provider and nominated individual demonstrated they were caring and it was clear they wanted to provide people with safe, effective and person-centred care, they and the additional management support demonstrated they lacked the skills, knowledge and experience to achieve this.

Where concerns and issues were brought to the management teams’ attention, they did not demonstrate a realistic understanding of the widespread nature and seriousness of concerns identified. Further, they could not assure themselves that effective actions would be taken to address the issues.

We requested multiple records as part of this assessment; these were not always produced by the agreed deadline or at all. Those that were received, failed to demonstrate the full extent of concerns we raised had been understood and acted on effectively.

People, staff and relatives were not always provided with opportunities to speak up.

Although people, relatives and staff felt able to speak up systems were not in place to support the formal sharing of feedback. There was insufficient evidence that concerns were effectively investigated, outcomes shared, and improvements made.

The provider’s whistleblowing policy did not contain up to date information or contact details for agencies staff could contact to raise concerns. Therefore, we were not assured the provider’s policies and procedures were effective in providing staff the information they needed.

We requested evidence of staff supervision and appraisals; the management team were only able to provide supervision records for one staff member which indicated their last formal supervision was completed in February 2024. On review of these supervision records we noted the staff member had made requests and suggestions which would support their and other staff members abilities to help ensure people were provided with safe and effective care. However, we did not see any evidence which demonstrated action had been taken in response to the staff members suggestions.

We asked the provider what systems were in place to allow people, relatives, staff and visiting professionals to provide feedback on the service and make suggestions about care. The provider confirmed there was a suggestion box in place and there were regular conversations with staff, people, relatives and professionals. However, they confirmed no staff or relative meetings had been completed and there had been no recent quality assurance questionnaires sent. Therefore, we could not be assured all staff, people and relatives were given the opportunity to speak up and share views and suggestions to drive improvement.

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 provider was able to describe what and how reasonable adjustments would be made for staff should it be required. They told us, “No staff have any particular requirements at the moment but if they did, we would do everything we could to support them.” They gave us some examples such as additional breaks, private spaces to pray or time off if appropriate during important life events. All staff spoken with spoke exceptionally positively about the kind and supportive nature of the provider and nominated individual.

The provider failed to have clear responsibilities, roles, systems of accountability and good governance. They failed to act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

From discussions with the management team, they could not assure us that they had a clear understanding of their own or staff members roles, responsibilities and accountability. They lacked understanding of their regulatory requirements and responsibilities.

The management team failed to complete effective audits and quality assurance processes to ensure care provided was safe, effective and responsive to people’s needs. Where audits were completed, we identified significant shortfalls in the quality of these audits as they failed to identify the widespread and serious concerns we found. For example, medicine audits were not effective, when we requested medicine audits these were completed by the manager retrospectively after we requested them. We discussed this with the provider who told us the manager had collated information from the MAR charts to complete these audits. However, the completed audits described there were detailed PRN and variable dose medicine protocols in place for all people where required. This was not the case.

Systems and processes in place to gain people’s consent and make decisions were ineffective and did not demonstrate care was always provided in line with legal frameworks.

Systems and processes were not in place to support the mitigation of risks to people or continued improvements. For example, the manager told us, there had been no recent falls or incidents in the service. However, the records we reviewed demonstrated there had been 2 recent unwitnessed falls, one of which resulted in a head injury and there were several incidents of unexplained bruising and skin injuries. There was no detail to demonstrate what had been done in response to the incidents, the only detail was what had happened.

During our assessment we found the management team failed to Notify CQC of significant events, such as injuries, falls and safeguarding incidents. These are required to allow CQC to complete their regulatory duties and ensure ongoing safe and effective care is provided. Therefore, the provider was not working in accordance with CQC regulations.

The provider failed to ensure all relevant policies and procedures were in place and they did not have effective systems to demonstrate staff had read and understood the policies or that these had been embedded in practice.Although we were told some policies had been updated in January 2025, including the safeguarding and whistleblowing policy when we reviewed these, we identified they lacked important and up to date information.

All the above issues were discussed with the provider and manager, and we requested immediate assurances be taken to address the most serious of the concerns identified. We did not receive immediate assurances for all of the serious concerns identified.

The provider failed to understand their duty to collaborate and work in partnership, so services work seamlessly for people. They failed to share information and learning with partners or collaborate for improvement.

People and their relatives told us they were confident the service would contact healthcare professionals when required. However, during our assessment we found people’s specific needs were not always known or understood by staff and there was insufficient monitoring of people’s health. Therefore, the provider did not have the information required to help them ensure appropriate referrals would be made and information shared in a timely way where needed.

People experienced delays in having their health needs met. Records indicated people had not received sufficient fluid or had not opened their bowels which was not identified by staff or shared urgently with other health care professionals. This meant people were at risk of significant harm and ill health.

We received mixed feedback from professionals about how well the service worked in partnership with other agencies to drive improvement. A professional told us, they were always kept updated of peoples changing needs. However, other professionals told us they were not always called appropriately, notified of changes as required or requested to provide support in a timely way.

The provider failed to focus on continuous learning, innovation and improvement across the organisation and local system. They did not 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 no demonstrable evidence that lessons had been learned from accidents, incidents, or falls, due to the absence of meaningful action to review and analyse these events for trends, patterns, or opportunities for improvement.

Quality assurance systems were either not in place, inconsistently applied or ineffective, which limited the service's ability to drive improvements that promoted equity, positive outcomes, and enhanced quality of life for people using the service.

We found no evidence that learning from safety events was shared to inform and improve practice. This limited the provider's ability to deliver safe, responsive, and high-quality care.

The provider did not always support or enable staff to deliver person-centred care. Systems to ensure staff had opportunities to raise concerns or feedback were not established. Staff did not benefit from appropriate and effective training, frequent structured supervision, staff meetings, feedback or embedded lessons learned discussion to reflect on practise to develop their approach to providing person centred care.