Shangri-La 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 requires improvement. At this assessment the rating has changed to good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

At our last inspection the provider was in breach of legal regulation in relation to governance at the service. At this inspection we found improvements had been made and theproviderwas no longer in breach of this regulation.

This service scored 75 (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. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The deputy manager told us they felt staff confidence and morale had improved since the last inspection. Spot checks and formal supervision records showed staff were supported to carry out their roles. Recent staff meeting minutes promoted a shared purpose and supportive culture.

Staff said the managers and staff team were very supportive. They told us they felt able to speak up and were encouraged to do so. Staff confirmed team discussions were held about people’s care.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Since the last inspection a new home manager was in post. During this inspection the new manager was open and receptive to feedback and discussion and demonstrated their knowledge and values. A health and social care professional commented following a visit to the service, “The staff we worked with were very engaging as was (manager’s name) who is registering to be the new manager.”

Staff understood their roles and responsibilities and there were clear lines of accountability. The management team supported staff and encouraged them to develop their skills and experience. For example, staff had been given ‘champion roles’ and took part in audits of the service. Staff expressed how supportive the managers were. We observed the management team worked closely and effectively together.

People and their relatives spoke positively about the staff and management. A newsletter sent out in April 2026 informed people and their families that a new manager was in post and gave details how to contact them by email or in person.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff were confident about expressing themselves and raising any concerns to the management team. The provider had a policy in place for staff to follow, which included contact details for relevant agencies such as the local authority. We saw this information was also available to staff on the office board and there was a list of contact names for leaders in the service.

People and their relatives confirmed they felt confident to raise issues with the staff and management team and that these would be resolved.

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.

The provider had processes and procedures to promote staff equality and inclusion. The service had a diverse workforce and staff confirmed there was good teamwork ethos and supportive managers. Two staff members told us how the provider had adjusted their working hours and duties to support changes in personal circumstances.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Since the last inspection a range of audits and monitoring tools had been introduced to increase management oversight and quality assurance. For example, a new accident / incident log with learning outcomes was in use including monthly summaries to monitor any trends. The provider also used a monthly governance, operational and risk report to monitor the quality and safety of the service.

We found improvements in processes for assessing mental capacity and consent, records of care and medicines, monitoring of risks related to the environment, safeguarding systems, monitoring of staff training and competencies, and how organisational learning was shared and embedded within the service.

The home manager was applying for registration. The home manager was knowledgeable and confident about what, when and who to notify regarding safeguarding matters.

Staff ‘champion roles’, including for example safeguarding and dementia champions, promoted staff development and accountability.

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.

Records showed the service worked closely with external health and social care agencies. Care reviews took place regularly with the input of relevant partners. An external health professional who provided feedback said, “On the occasions where issues or queries have arisen, communication with the management team has been professional and concerns have been addressed appropriately.”Another health care professional told us the home manager had been receptive to recent advice in relation to moving and repositioning equipment and had set up refresher training for staff.

The home manager had sent out a questionnaire asking for feedback from people’s relatives. The home manager told us they were also arranging an introductory meeting for people’s families. The service ran regular open days involving the local community.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider had a plan for continuous service improvement, which included actions taken to implement advice from external professionals, such as the fire officer and the care homes team. Actions had been taken to strengthen safe moving and handling practices. More realistic fire drills were being introduced, including a planned night‑scenario. Other areas where improvements were noted were quality and safety audits, staff supervision and competency checks.

Staff told us they were asked and involved with how the home was run. Staff meetings took place and the minutes of these showed a learning culture was promoted within the service.