Wessex Lodge 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 good. At this assessment the rating has changed to 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 service was in breach of legal regulation in relation to Good governance at the service as quality and risk monitoring were not always effective. The provider had not identified all the quality, or risk concerns we found during our inspection. This meant prompt action had not been taken to address shortfalls.

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 clearly defined and inclusive vision, strategy, and culture rooted in transparency, equity, equality and human rights, diversity and inclusion, and engagement. Staff and leaders expressed genuine passion for their roles, contributing to a positive and committed working environment.

The registered manager described the use of values-based recruitment to ensure new staff aligned with the ethos and culture being cultivated within the service. This approach supported the development of a team that prioritised compassionate, person-centred care and upheld the provider’s strategic goals.

Leaders were open about the challenges involved in driving cultural change and provided specific examples of the steps being taken to support this. These included staff engagement initiatives and ongoing efforts to embed shared values across all departments. This reflected a listening culture focused on learning and improvement.

The provider’s approach demonstrated a commitment to promoting equality and diversity, understanding local challenges, and ensuring that staff at all levels were aligned with the strategic direction of the service.

Leaders did not always have the skills, knowledge and experience to lead effectively such as ensuring audit systems were effective. We identified a breach of legal regulations and concerns relating to records and governance. Leaders had not independently identified or acted on all these issues prior to our assessment. This indicated some skills development was needed. Leaders understood the context in which care, treatment and support were delivered and embodied the values and culture of the organisation. They led with integrity, openness and honesty, including when discussing known shortfalls.

Feedback highlighted that the registered manager and deputy manager brought complementary skills to their roles, contributing to a balanced leadership team with clearly shared values and goals. Leaders were visible and led by example, modelling inclusive behaviours and fostering a culture of transparency, learning and continuous improvement.

Leadership development was supported through internal and external networking, enabling the sharing of good practice across teams and with wider professional networks. Leaders demonstrated awareness of organisational challenges and were committed to addressing them collaboratively and constructively.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The service had systems and processes in place to enable people and staff to speak up. A whistleblowing policy was in place and staff knew where to go for support and the processes to follow. The registered manager told us they operated an open-door policy and encouraged people, relatives and staff to speak up freely. Leaders demonstrated an understanding of their responsibilities under the duty of candour. The duty of candour is a legal responsibility for health and social care providers to be open, honest and transparent when something goes wrong with a person’s care or treatment. Throughout the assessment, we found staff, leaders, and senior leaders to be open, honest, and transparent in their engagement with us. They responded to our enquiries with candour and demonstrated a willingness to reflect on feedback and acknowledge areas for improvement. This approach contributed to a culture where speaking up was encouraged and where concerns were increasingly seen as opportunities for learning and development.

The service demonstrated a clear commitment to valuing diversity within its workforce and worked towards fostering an inclusive and fair culture. A diverse staff group was employed, representing a wide range of backgrounds and experiences.

Staff were provided with information about independent services they could contact confidentially for support with their health and wellbeing. The provider’s policies and procedures supported equality, and staff shared examples of being supported through reasonable adjustments. Staff told us they felt everyone was treated equally.

These practices reflected the provider’s efforts to create a workplace that promoted equity, supported wellbeing, and ensured fair treatment for all staff, including those with protected characteristics. The inclusive culture contributed to a positive working environment and aligned with the organisation’s wider values and strategic goals.

The provider did not act on the best information about risk, performance and outcomes. Governance arrangements were in place, but they were not effective in ensuring safe, high-quality and sustainable care. Systems of accountability and oversight had not always been followed, and risk management processes did not reliably capture or document all relevant information. For example, accident and incident records lacked sufficient detail and analysis, and these gaps had not been identified by the provider. Necessary actions to mitigate risks were not always recorded, and improvements in record-keeping were needed, as outlined in the Safe key question, to ensure care plans reflected clear and detailed risk information.

Audits were completed, but they did not fully identify all the concerns found during the assessment, such as gaps in care assessment and planning, contradictory records, and insufficient documentation to guide staff. This limited the provider’s ability to monitor service delivery effectively and act on performance data to drive improvement.

However, the service expressed a commitment to quality improvement. Leaders acknowledged that improvements were still underway and demonstrated a willingness to drive change. While they were aware of some of the concerns identified during the assessment, they had not recognised all of them, for example, the lack of robust records for accidents and incidents. However, leaders were responsive to feedback and began taking action to address concerns during the assessment.

The registered manager and provider were unable to demonstrate that robust oversight of the service was in place. Therefore, the service was in breach of legal regulation in relation to good governance.

The provider understood their duty to collaborate and work in partnership. Staff and leaders shared information with external professionals, and one professional told us they had an effective working relationship with the service, noting that staff were knowledgeable about the people they supported.

Records were available to be shared with health and social care professionals as required, supporting continuity and coordination of care. Where people needed support from external services, for example, attending appointments, the provider ensured these were arranged in a timely and responsive manner.

Both leaders and staff shared examples of partnership working with external agencies and professionals, illustrating a proactive approach to collaboration.

The provider had systems in place to support learning and improvement, but these were not consistently effective in identifying and driving change. While shortfalls were identified during the assessment, the provider was responsive and had begun taking action to address these areas. Time was needed for newly introduced improvements to be fully implemented and embedded into practice.

There were systems and processes in place to promote learning across the organisation. These included regular operational updates, team meetings, handovers, and monthly analysis of accidents and incidents. These mechanisms supported reflection and collective problem-solving.

However, concerns remained around the lack of consistent records and governance systems, which meant that opportunities for improvement might not always be identified or acted upon. This limited the provider’s ability to measure outcomes and ensure that learning translated into sustained service development.

Despite these challenges, leaders and staff demonstrated a willingness to improve and engage in learning.