Archived: Quenby Rest 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 Inadequate. At this assessment the rating has remained 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 provider was previously in breach of the legal regulation relating to good governance. Improvements were not found at this assessment and the provider remained in breach of this regulation.

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. The provider had still not developed a clear vision, strategy or set of values, aims and aspirations for the service which staff could follow, despite telling us in their PIR (Provider Information Return), after the last inspection, that the 6 Cs were being adopted as the shared vision of the home. The 6 Cs are core values in healthcare: Care, Compassion, Competence, Communication, Courage and Commitment. The provider told us they would be displayed on a poster, discussed in meetings and in staff supervisions. This was not evident during our assessment. Staff spoken with were not aware of them and the manager told us the PIR was written by an external consultancy and the 6 Cs value system was not being adopted. The new manager told us their vision was to provide safe care, and the values were to provide a homely environment and person-centred care, they did not fully understand or describe the values that underpinned this. The provider leadership did not demonstrate how they supported the management team to place people at the heart of the service, protect them from harm and enable them to live their best life.

The provider did not lead with integrity, openness and honesty. Following our last assessment in March 2025 the provider appointed an external consultancy for guidance and support, and leadership. Recruitment documentation showed the provider had no assurance leaders had the required competencies and sector experience to run and improve the service effectively. Previous employments were not explored in depth to give assurance of ability or a background working in residential care with older people who have dementia. Leaders could not demonstrate experience linked to dementia care. They told us they did not have a job description and were uncertain of their role and responsibilities. When we returned to the service on 24 October, we found the head of care had resigned with immediate effect.

The manager was not knowledgeable about the outstanding issues and priorities for the quality and safety of the service. The provider had not shared with the new management team and consultancy an overall plan for the improvement, direction or development of the service to ensure they knew what was expected of them and that they could deliver it. The manager told us that at the time of their appointment the provider had not shared with them a realistic understanding of the widespread nature and seriousness of concerns identified by CQC, the warning notices served and expected dates for compliance. They were also not aware, until informed by the deputy manager of a serious incident that had occurred resulting in the death of a person. The manager told us, “I had conversations with the provider and director, but I was not aware there was so much to do.” A member of staff told us, “The manager wants to make the service better, but initially didn’t really understand what needed to improve.” A relative told us, “I have always felt that the owners are not supporting them (the service) as much as they could be.”

Roles and accountabilities for managers and leaders were not clearly defined. There was no structured induction being undertaken to cover the responsibilities of the manager. The manager was unable to tell us about any structured and formal support being provided to them in their new role to address issues and priorities for the safety and quality of the service. The manager told us that the external consultancy provided support once a week. When they were asked what that support looked like they told us, “Well, they ask me what I need, and they help by doing an audit or supervisions.” We asked how this supported them, and they replied, “It’s good to have a new set of eyes, they may see something I don’t, they guide me on issues if I am unsure of something. I also have [Director of Care] for support, and I have had a supervision with [the provider].” This was not formalised or recorded.

Although leaders had held meetings with people, their relatives and staff to communicate the service position, meeting minutes showed they were not empowered to be part of the solutions. One relative told us, “There was a meeting with the owner about 2 months ago with an explanation of what was happening and what they were doing.” Another relative said, “My [Person] went to a meeting about the whole situation. They met the owner and felt there was a decent exchange of views. They were told there would be a plan put in place, but there has been nothing in writing, so hope they stick to that.”

Relatives had mixed views on the visibility and appointment of the new manager. Comments included, “I have met the new manager, and they certainly seem to have got some wheels in motion and has noticeably brought the team together,” and “I don’t remember meeting the last manager at all. Mind you, I haven’t met the new one yet either.”

People did not always feel they could speak up and that their voice would be heard. The provider did not actively promote staff empowerment to drive improvement. Staff were not involved or engaged in an improvement plan and were not aware of their role within any improvement processes. Staff were not aware of the contents of the previous CQC assessment report from March 2025 or where improvement was needed. One staff member said, “We had a meeting after, there are more checks now to see if we are doing things right.” Another staff member told us they were only aware of the IPC (infection prevention and control) report and areas for improvement.

Minutes of staff meetings showed concerns were raised by staff, but they did not include any actions being taken forward to address them or that concerns and/or actions were reviewed at next meeting. For example, a staff member raised concerns about work pressures at key times when everybody needs care, particularly in the morning. The manager, in response stressed ‘time management’ but no plan or direction on how to manage time more effectively was offered. The manager told us, “I take staff ideas on board and that is working well.” Staff told us the manager had put in place a suggestion box. They confirmed suggestions had been made by staff about reorganising break times, because staff were not always getting their breaks. They said senior staff were trying different time regimes to see which works the best but there were still times when staff were not getting breaks.

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. The provider employed a diverse workforce under the sponsorship scheme. Our last assessment found training was not pro-actively planned for where there were inequalities in staffs’ abilities, and opportunities for learning and development were poor. No consideration or adjustments were made to how staff training was delivered, which was mostly on-line, to reflect staff’s diverse needs. We were told at that time informal English language was being sought to help staff improve their communication skills in both spoken, reading and written language. This assessment found this had not happened. Feedback from people and relatives advised that language with some staff whose first language was not English continued to at times present a barrier to some people using the service. One person told us, “I can’t understand the staff.”

There was a lack of systems in place to promote workforce equality, diversity and inclusion that would help to ensure all staffs specific support and learning needs were identified and met, including equality and diversity focused supervisions. The manager told us they embraced and valued diversity in the workplace. To promote an inclusive environment the service had recently hosted multicultural events when staff dressed in clothes and brought in food representative of their country and culture. People and relatives provided positive feedback about these events. One relative told us, “There was a garden party where they celebrated Diwali, and all the staff were in their costumes.” The manager advised of reasonable adjustments made to accommodate staffs protected characteristics such as time allocated for religious observance and flexible working for staff with ill-health.

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.Whilst there has been a new management structure, including the recruitment of a care director, home manager and a consultancy firm it was not clear who was responsible for certain actions, and there was an inconsistent approach to ensure effective development, improvement and sustainability to the quality and safety of the service. The provider did not have an overall development plan, to plan for, drive and sustain improvement as well as inform the new management and consultancy of the direction of the service and what was expected of them. Governance, management, and accountability arrangements still needed to improve.

A quality culture still needed to be established to ensure any future shortfalls would be independently identified and pro-actively addressed and improvements were being embedded and capable of being sustained. Although new auditing processes have been introduced these were still not being used to provide an accurate overview of the service; ensure proper monitoring and review, identify shortfalls or inform an ongoing plan for improvement. Audits remained a tick box format, with limited evidence of how these were identifying and acting on issues to improve the service. They had failed to identify the compromised quality and safety issues found during the assessment of the service, and the approach continued to be reactive and not proactive.

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 management team engaged well with the local authority quality improvement team; however, they had not engaged so well with the Commission to improve practice and provide safe care. Information requested had not always been forthcoming or information that had been provided was not always relevant to what was requested. Responses to requests to address serious concerns identified during our assessment did not demonstrate effort and urgency that was proportionate to the high risk identified, and this led to the Commission taking urgent enforcement action to mitigate risk during the assessment.

The provider did not 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.This assessment found there was no proactive development of the service. There was no plan about how the service kept up to date with developments in dementia care to ensure care provided was appropriate and in accordance with best practice. There continued to be a lack of recognition and understanding of the wider aspects of living with dementia and related needs. Learning gaps and further development for staff were not identified, and opportunities were not offered to staff to progress and grow in their roles to improve people’s experiences.

There was no evidence to demonstrate the service engaged in local and national forums or development groups which would assist in gathering best practice knowledge to support improvement in the service, for example dementia care. Quality checks on people’s experiences were not carried out and reviewed to see if anything could be done to support people in different ways to improve their experiences. There were no processes in place to review any lessons learned or any changes in practice to see if they worked well or not.