Leiston Old Abbey Residential 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 inspection we rated this key question good. At this inspection the rating has changed to 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 service was in breach of legal regulation in relation to governance.

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.

Staff told us they did not attend regular all staff meetings to keep them, up to date with ways of working, to ensure the staff team understood their roles and responsibilities and were working together. A staff member said, there were meetings for example, night staff, and other departments, but no whole staff meetings so staff could discuss any issues and get them rectified. The registered manager told us it was difficult to get the whole staff together for meetings and they were considering ways of delivering meetings in smaller groups to ensure they all had the same message. A staff member told us a lot of guidance for staff was sent electronically, rather than face to face and when there were issues with staff performance, this was not always addressed, “There are no repercussions for their actions... feels like it is complacent here.” Another staff member said they felt the service would improve if everyone worked together as a team to support each other, “Sometimes feels like fighting a losing battle.”

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.

Since our last inspection, there had been a change in the registered manager for the service. During this inspection we identified considerable deterioration in the service and the provider had not sustained the previous rating of good. The provider’s own governance processes were not robust enough to independently identify shortfalls and address them.

Some staff told us the provider was not always approachable and did not communicate with them when visiting to ask for their feedback about the service. When pointing out some of the shortfalls identified at our inspection to the provider, they told us staff had been told by about the requirements of their roles. However, we found there was a lack of continuous monitoring until the issues had been resolved.

We received positive feedback from staff, people using the service and relatives regarding the registered manager’s caring attitude and availability. A person’s relative said, “[Registered manager] and the team are wonderful, we’re very lucky.” Another relative told us they felt the registered manager tried their best, but felt their, “Hands were tied,” and the issues in the service were down to the provider.

During our first visit to the service, there was a power cut. Staff had acted appropriately, for example, by calling the power supplier. However, information had not been shared with us by the provider about additional power cuts until we had been made aware of them happening by a person who used the service. Whilst the power cuts were no fault of the service, there was no long term forward planning to reduce the adverse effects on the people using the service, for example, not being to access the lift to go to bed.

The registered manager told us how they had challenged other services when people could not access their finances. In the interim, staff were purchasing items and receipts were being maintained until they could be reimbursed. Whist this demonstrated staff were willing to go over and above the requirements of their role, there was no evidence that the provider had stepped in and had developed systems to reduce staff spending their own money when at work.

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

There was a procedure in place to guide staff in reporting, for example, bad practice, known as whistleblowing. This was understood by staff and they told us they would report concerns. However, staff told us they felt when they reported concerns, for example, about colleague practice, this was not always addressed and issues continued. A staff member told us leaders were, "Not strict enough.” The provider told us staff may not always be aware of actions taken when information had been received due to confidentiality.

People and relatives told us they could speak with the registered manager where needed, and they were available. We received mixed feedback about if relatives were always kept updated about their family member’s wellbeing.

There was a duty of candour policy in place, however, we were not assured this was fully understood by the provider and registered manager. We asked for examples of when they had acted on the duty of candour, and we received responses relating to sharing information with the commissioners of the service. Prior to our assessment we had received concerns from a relative relating to an incident, where they had not been given full details of what had happened until they had asked for it.

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.

We received mixed views from staff about the culture in the service, whilst some staff told us there was a positive culture within the service and they all got on well and supported each other, other staff told us some colleagues worked well and others did not. A staff member said they felt there was a divide in the staff team, and some staff were not challenged when they were not working with their colleagues to ensure people always received the care they needed. Another staff member said, “We get to hear what we have done wrong, never praise.”

The provider did not have clear responsibilities, roles, systems of accountability and good governance.

The governance systems in place were not robust enough to either identify or address shortfalls found during our inspection. Issues in the infection control had not all been identified and addressed, and the provider and registered manager told us staff had previously been advised about their responsibilities, despite this the shortfalls remained. The registered manager told us they would send us infection control audits, these were not received.

Audits were not routinely done and where shortfalls had been identified by the registered manager, these had not been included on an improvement plan with timescales for improvement and there was no follow up documented. For example, a training audit in January 2026 had identified significant shortfalls in staff training, staff were advised of what they needed to do by February 2026, however, there was no documentation to show this had been followed up. The training matrix provided to us still contained gaps.

There were no audits in place to support the provider and registered manager to assess that people’s call bells were attended to promptly. The registered manager told us the system used did not provide, for example print outs of response times. They had not considered alternative methods of checking. However, the registered manager told us they would do this going forward.

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 local authority commissioners told us they were working with the service to make improvements. This included a range of workshops for staff. Staff told us they felt these workshops were beneficial and they valued the opportunity to have face to face learning opportunities.

The provider’s Provider Information Return received prior to our assessment identified barriers faced making it difficult to provide good quality care, “We are being asked to do so much more without real training. There was a time when district nurses would come in and show us different dressings etc and what we needed to use them on etc. now we are just expected to get on with it. We are expected to do so much more paperwork, we are expected to be computer trained, have knowledge on all different types of illness, understand different diets, this is just care staff.” This demonstrated the provider did not have robust training systems in place to support the staff team to meet people’s needs and to work alongside other professionals.

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.

There was a lack of forward planning for ongoing improvement. We were not assured the processes in place for ongoing improvement were robust. During our inspection, we found when improvements had been made, they were not sustained and embedded in practice, resulting in the shortfalls being repeated.

There was a lack of robust governance systems to support the provider and registered manager to independently identify and address shortfalls, which did not support ongoing improvement.

The improvement plan for 2025 had identified improvements needed in the car park and replacement of the passenger lift which had been completed. The medicine system was being changed to an electronic system and plans in place to upgrade the electronic care planning system. There was no reference in the improvement plan which identified the shortfalls we had noted during our assessment.

The service took part in research, for example, a recent research activity relating to loneliness.

A staff member told us the registered manager provided face to face moving and handling training. We asked for evidence of when the staff had received this training. The registered manager told us they needed to find it and would send it to us. At the time of writing this report, it had not been received.