Pelham Manor

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.

The provider was previously in breach of the regulation in relation to good governance. Improvements were not found in the governance of the service and the provider remained in breach of this regulation.

This service scored 61 (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.

Staff understood the aims of the service were to support people with a learning disability and autism to go out in the community and lead active lives. Staff said they were motivated to support the people in their care and this was confirmed by our observations. When staff spoke with people they did so as equals, joining people into the conversation although some people were not able to verbally respond. Staff said there was good support amongst the staff team and they felt assured this would continue with the appointment of a new manager. A relative told us, “There is a new manager and we have spoken to him a couple of times. The staff have given good feedback about him.”

Relatives described the service as having a positive environment. Comments included, “They are honest if things go wrong and you can talk to them about it”, “There is always a good atmosphere with laughter going on” and “When I visited it was relaxed and restful."

The provider had leaders who embodied the culture and values of their workforce and organisation.

The manager had been in post for a week and had previously worked at the service. The provider shared with us their plans for registering a manager at the service.

Although the manager had only been in post for a very short period staff were positive about the support they had received. The manager was still in their induction period. They said they had contacted everyone’s family members to introduce themselves and this was confirmed by relatives. Relatives said they appreciated this as the previous manager and deputy had left suddenly. They said the manager reassured them they could contact them directly if they had any questions or concerns. A relative told us, “It was not well-led. The interim manager was nice. Now a new broom has arrived and I’m optimistic.”

During the assessment, the office door was open when the management team were available. People walked in and out of the office and senior staff dealt with people’s requests or directed them to another staff member who could help them more effectively.

The provider had not always fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff felt able to voice their views at team meetings or supervisions. They also knew how to raise concerns with the provider via the providers whistle blowing policy. Some staff told us, although they had not suffered detrimentally from raising concerns, they had not always been listened to. The new manager was aware of this and was working towards developing a more positive culture where people felt they could speak up and their voice be heard.

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.

Staff spoke positively about their experiences at work and told us they were treated fairly. The provider was aware of their responsibilities in relation to the Equality Act 2010. Staff were asked if they required any reasonable adjustments which were then put into practice. Training in equality and diversity was part of staff induction and regularly refreshed as part of staff development.

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.

The provider had continued to fail to ensure there were effective governance systems at the service. This was despite sending us an action plan after our last inspection, giving assurance that effective auditing processes had been established. The management team had carried out a range of audits, but these varied in quality. The home's audit of medicines in July 2025 had not identified any shortfalls in the management of medicines. However, the providers quality team did find shortfalls during an audit on 29 September 2025 in staff training and a lack of records of the actions taken when there had been a medicines error. At our assessment we found neither of the providers audits had identified the discrepancies between medicines records and the actual number of people's medicines held in stock.

The provider's quality audit on 29 September 2025 also found shortfalls in that care records did not always contain specific support guidance and that they were not always easy to access. An action plan had not been developed to address shortfalls, and they remained at our assessment. The manager took immediate action and developed an action plan with timescales detailing the changes they were making to improve quality in these areas.

At the last inspection of the service, we were given assurances that the views of families and advocates would be regularly sought about the service through feedback questionnaires. However, family members were not aware of being asked formally for their views of the quality of the service such as what it did well and how it could improve.

The provider did not hold accurate records of staff training. Although staff told us they had completed training relevant to their role, the staff training matrix had not merged the training staff had completed from four different training providers and was therefore inaccurate. As a result, the provider could not be confident staff training was up to date in all essential areas.

Services providing health and social care to people are required to inform the CQC of important events that happen in the service. This is so we can check that appropriate action has been taken. The provider had appropriately informed us of events and incidents.

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 had partnerships with social and health care professionals to ensure good, joined up care for people. This included members of the community learning disability, speech and language therapists and psychologists.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

The provider had not effectively used their own auditing processes, meetings between service managers across the organisation, feedback from people and/or their representatives nor previous inspection reports as the basis for making service improvements. As a result, there continued to be shortfalls in risk management and the management of medicines.

The provider and manager were receptive to the feedback we gave after the assessment. The manager took action to address some areas immediately when they were brought to their attention to minimise the impact to people’s safety.