Southdown 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.

This service scored 50 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

There was no clear or consistent shared direction at Southdown Nursing Home. Staff told us communication between management layers was inconsistent, contributing to confusion about processes, expectations, and prioritisation of tasks.

The absence of a defined shared culture contributed to variable practice across teams. Staff shared differing views about leadership presence, with some reporting strong support and others saying management were not always available or aligned. These inconsistencies reflected a lack of unified, shared values.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Leadership at Southdown Nursing Home was inconsistent between the provider and the day to day management of the home, leaving gaps in oversight and decision‑making. For example, confidential records were left unsecured in communal locations. This had been identified previously during a local authority visit and had not been addressed in a timely way.

Staff reported that although some leaders were approachable, others were not always visible or supportive. There were also concerns about leadership style. A staff member reported being spoken to in a derogatory manner by a senior figure when tasks were not completed as expected. These behaviours did not support a respectful or inclusive leadership culture.

People did not always feel they could speak up and that their voice would be heard.

Freedom to speak up arrangements did not align with best practice. The service’s appointed Freedom to Speak Up guardian was the manager, which is not considered appropriate because it creates a conflict of interest and may deter staff from raising concerns.

Some staff expressed confidence in raising issues, but others did not. Some staff described feeling unable to speak openly. The concerns identified with the culture within the home meant the service did not facilitate a space where staff felt protected and supported to speak up to improve the quality and safety of care.

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.

There were pockets of positive practice in supporting individual staff needs, such as adjustments for a staff member with health conditions and support during Ramadan. However, staff feedback showed inconsistencies in how fairly policies were applied. Rotas were issued with very short notice, and annual leave restrictions disproportionately affected staff with families overseas. Several staff said the inability to take longer leave caused significant emotional strain.

Some staff described supportive working relationships and good teamwork, while others spoke about being treated dismissively or rudely by senior figures, which does not promote an inclusive working environment.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance systems at Southdown Nursing Home were under‑developed and did not drive sustainable improvement. For example, it had previously been identified that care records and confidential information were visibly accessible in communal areas and this had not been acted upon.

Leaders had introduced numerous audits and new systems; however, these lacked structure, oversight and follow‑through. For example, all audits were conducted on the same day by the same person, without evidence they were informing improvements or being used to monitor performance effectively. Audits were completed but were not used meaningfully. There was no evidence of trend analysis, action planning, or oversight of whether identified improvements were implemented.

Learning from incidents and complaints was inconsistent. Incident logs lacked detail and were not analysed for themes. Complaints were logged but not evaluated at service level to drive improvement.

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 provider had previously worked well with other agencies and health and social care providers. And we saw professional involvement continued to support individual people. However, partner agencies reported reduced engagement from the provider, and they raised concerns about leadership responsiveness.

There was also limited evidence of engagement with people and relatives to shape the home’s direction. While satisfaction surveys had been completed, they had not been analysed, limiting opportunities for learning or cultural reflection. Leaders had not established clear mechanisms for encouraging views, acting on feedback or demonstrating how this informed improvements.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Leaders had begun to adopt new systems, such as implementing an electronic records platform and replacing manual equipment like slings. However, these actions were largely reactive and often initiated only after concerns were raised by relatives, staff or external agencies. The service had not embedded a learning culture.

Despite this, leaders had started developing a system to further inform staff learning and reflective practice following any incidents that occurred. We will review the effectiveness of this system at our next assessment.

Leaders told us they also had plans to improve the management and oversight of the quality and safety of service delivery through the introduction of a lead nurse and clinical lead. However, these positions were not in post at the time of our assessment, so we were unable to evaluate the impact of these roles.