Selly Park

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 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.

This service scored 71 (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 registered manager had been in post since September 2025 and had a clear vision for the future of the service. Staff were aware of, and engaged with, the improvements being introduced and spoke positively about the direction of the service. The registered manager told us they were fully supported by the nominated individual and provider to implement the changes they had identified as necessary to improve service delivery and outcomes for people.

Staff spoke of the positive impact the registered manager had on the service since their arrival. There was a positive, compassionate listening culture put in place by the registered manager which provided people and staff alike with the opportunity to raise any issues they may have and to be confident they would be listened to.

The registered manager, supported by the nominated individual, had addressed the initial areas of concern they had on arrival in post. They told us there was always ‘room for improvement’, their initial plan was to move all care plans onto the electronic care planning system and then move to staff files and finally ensure a robust training plan for all staff was in place. We noted these initial actions had been completed and staff reported the positive impact these changes had made to service delivery and their work environment.

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.

Staff spoke positively of the work environment promoted by the registered manager and deputy manager, both of whom were clearly visible throughout the working day and led by example.

Staff felt well supported and well trained. They were aware of their roles and responsibilities and demonstrated compassion towards the people they supported. Staff were encouraged to attend additional training, to develop their existing skills and take on ‘champion’ roles in the home. Staff spoken with who had taken advantage of these opportunities told us they felt valued and supported. The registered manager had introduced an ‘Employee of the month’ award, which had been well received by staff.

All staff spoken with talked of a positive working environment and described the staff team as a ‘family who support each other’.

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

Staff were aware of the provider’s whistleblowing policy and were confident if they raised concerns they would be listened to.

Staff were given the opportunity to raise any concerns through staff meetings and one-to-one supervisions. A member of staff had been given the role of ‘speak up ambassador’. They told us, “If staff have a concern they will go to the manager or me. We all work as one.”

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 told us they felt they were treated fairly by management and felt the service was a good place to work.

A number of staff described how the registered manager had recognised the need to support them to make reasonable adjustments to their working day in response to their individual and diverse needs. This included supporting staff with particular family commitments and to attend healthcare appointments.

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.

The registered manager had introduced a range of audit processes intended to provide effective oversight and quality assurance across the service. Significant efforts had also been made to implement a new electronic care planning system.

The registered manager had introduced a range of improvements within a relatively short timeframe, and both people using the service and staff spoke positively about the impact these changes had made. The nominated individual had also strengthened oversight by introducing an additional layer of scrutiny to the service's audit and quality assurance processes.

However, despite the range of quality assurance and governance measures in place, these systems had not been consistently effective, as a number of concerns identified during the inspection had not been recognised through the provider's own audit processes.

These included omissions within some care plans, environmental issues, staff files and inconsistencies within kitchen audit documentation, where records had been signed in advance by both the chef and the registered manager. It is acknowledged that all concerns identified during the inspection and shared with the registered manager were responded to promptly, with immediate action taken to address the issues raised. However, it remains a concern that the existing layers of oversight, including monitoring by the nominated individual, had not identified these matters prior to the inspection. The nominated individual advised that further plans were in place to strengthen the service's quality assurance arrangements. These included the introduction of a daily staff booklet outlining roles and responsibilities, alongside daily monitoring checklists designed to improve oversight and accountability.

The registered manager and the nominated individual were open and transparent during the inspection process and responded to all concerns immediately, providing reassurance to the inspection team.

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 was supported by a variety of professionals including healthcare professionals. The service had worked alongside and received support from healthcare professionals and had acted on the advice and guidance given by them. The registered manager had plans to build relationships with the local community. They shared that the local deacon visited the service weekly and the catholic priest on a Saturday. The registered manager told us, “I have lots of ideas” and was keen to strengthen community links within the area.

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.

Systems were in place to ensure lessons were learnt from accidents and incidents, with outcomes used to inform ongoing improvements within the service. An action plan was maintained to support oversight of the service, monitor progress, and identify areas requiring attention or further action. The registered manager and nominated individual were open, transparent and receptive throughout the inspection process. They engaged positively with inspectors, responded constructively to feedback, and demonstrated a willingness to address issues identified to support continuous improvement within the service.

Staff spoke positively of the changes introduced by the registered manager and the how information was shared to ensure lessons were learnt from events. Staff told us they felt listened to and empowered by the registered manager. One member of staff described the registered manager as ‘amazing’, adding 'I feel very comfortable around [registered manager’s name], they are all ears and a breath of fresh air, since they came the atmosphere is totally different."