Purley Gardens Care 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. This is the first assessment for this re-registered service. This key question has been rated requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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 did not always have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

We received mixed feedback from relatives and staff about the culture within the care home during the tenure of the previous registered manager, but most people now felt the culture was gradually starting to improve under the leadership of the newly appointed managers. Comments included, “The culture here before the new managers came was one of fear, discrimination and detriment”, “I wasn’t proud to work here because the culture was so poor” and “It wasn’t a great place to work back then when the [name of former registered manager], but I am confident the new managers will turn things around”. Senior managers acknowledged the care homes culture under the leadership of the former registered manager was not always based on transparency, equality, and engagement, but were confident the new management team with their support would ensure the culture within the service returned to being a positive one once more. The new managers were now routinely using individual and group meetings to remind staff about the provider’s underlying core values and principles.

Not all the care home leaders had understood the context in which the service delivered care, treatment and support. They had not always embodied the culture and values of their workforce and organisation. However, the new leaders have the skills, knowledge, experience and credibility to lead effectively and were doing so with integrity, openness and honesty.

The services registered manager and former deputy manager both left earlier in the year [2026] and in the interim period 2 different temporary acting managers and a permanent deputy manager have been in day-to-day charge of the care home. Senior regional managers confirmed they were supporting the new acting manager and deputy manager and that a new permanent manager had now been appointed who was due to commence working in the care home this summer.

The care home has continued to experience high rates of management turnover. In the last 3 years 4 different registered or temporary acting managers have led the care home.

We received mixed feedback from relatives and community-based care professionals about how the care home had been managed in recent years, with most expressing concerns about the previous registered manager leadership style. Comments included, “The place wasn’t managed at all well by the previous manager [registered]”, “Most of the managers here are available, and continue to be as professional and approachable as ever. However, the home managers keep changing which negatively impacts on the continuity and quality of the care people receive here and has adversely affected staff morale and their confidence in management. The care home could only benefit from having a more stable and to be honest competent management team in place” and “There has been some instability with regards the management of Purley Gardens in recent years. I did not feel the last manager [registered] we had here was focused enough on the quality and safety of the care people living here received.”

Feedback we received from staff working in the care home was equally mixed with similar concerns raised about constantly changing managers and the leadership approach of the former registered manager. One staff member told us, “The former managers were out of touch with what was happening in the home. Staff were also not treated well and staff job satisfaction and morale remained low as a direct result”. Another added, “The way the last manager [registered] ran Purley Gardens was inconsistent and very top-down, do as we say type of approach. I don’t think the staff felt listened too, respected, valued or supported by the previous manager [registered].

The provider did not always foster a positive culture where people felt they could speak up and their voice would be heard.

People told us they had confidence in staff and the new management team to take their views seriously and act to address any issues that were raised. Most relatives also expressed feeling confident any concerns they raised would now been listened to and acted upon.

However, staff working in the care home consistently told us they did not feel able to speak up or confident that their voices and opinions were always heard and taken seriously. Feedback included, “I felt our legitimate concerns which we raised with managers in the past were either passed off or not handled appropriately”, “Complaints were not always dealt with in an open, transparent and timely way by the former managers” and” We remained in fear of raising concerns to management because some of us have felt victimised and bullied when we have spoken up”. An internal investigation conducted by senior managers identified significant issues in relation to how some concerns and complaints had been investigated, resolved, and recorded by the former registered manager. In addition, the services most recent staff survey [published 2025] revealed about half the staff surveyed felt the managers in day-to-day charge of the care home at the time did not always listen to them or take their opinions seriously.

The provider had an accessible complaints and staff whistleblowing procedures in place, which set out clear expectations for how concerns should be reported and dealt with by the provider.

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 arrangements to support equality, diversity and inclusion. Equality and diversity policies were in place to ensure staff were supported to work in an environment that was free from discrimination. Staff had opportunities for career progression and had their diverse cultural and religious needs respected. Staff were also supported through relevant training and supervision to inform their knowledge and understanding of equality in the workplace.

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 provider had established governance system. However, these systems had not always been operated effectively. This was because they had failed to identify and/or address multiple issues we identified at this assessment in relation to how staff were deployed within the care home, staff morale, and overall work performance being routinely appraised; the care homes environment being suitably decorated and adapted to meet the needs of people living with dementia; and ensuring information about people’s personal care needs and wishes always remained up to date and accurate.

In addition, an internal investigation identified significant concerns in relation to the effectiveness of the previous registered managers approach to oversight and scrutiny of the care home. This included issues not being picked up and/or resolved in relation to the overall cleanliness of the environment, how some care-related incidents, concerns and complaints were dealt with, risk assessing and management, staff recruitment and support, and the culture within the care home not always being based on transparency, equality and engagement,

These issues notwithstanding the services new management team with the support of senior regional managers had begun to improve the effectiveness of their governance systems. This included routinely conducting multiple quality monitoring tasks, such as managers taking daily walking tours of the building to observe staffs working practices, checking records and gathering the views and experiences of people living and visiting the care home. The outcome of all these checks and audits fed into the providers centralised electronic systems which records and reviews all the key service data, to identify themes and trends which might emerge. Managers and staff held regular meetings to discuss and analyse their findings, identify themes, learn lessons and agree actions they needed to take to address any gaps in performance and improve.

Managers understood and demonstrated compliance with regulatory requirements. They also understood their responsibility to provide honest information, suitable support and to apply duty of candour where appropriate.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

The provider worked constructively with partners and the local community to support people’s care. The service had established positive working relationships with multiple community-based health and social care professionals and agencies, including the local GP surgery, pharmacists and hospice services. Staff described good access to advice and support from community professionals when needed. The care home also engaged with community groups and activities, such as schools visiting and external entertainers.

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.

Systems were in place to review performance, identify learning opportunities and adapt practice. The provider routinely analysed the outcome of audits and checks they regularly conducted to identify performance shortfalls and learn lessons. When lessons needed to be learnt, the provider developed time specific action plans which set out clearly what, how and when they needed to take steps to improve the service they provided people. A community-based care professional told us governance systems had not been effectively operated by the previous manager [registered], which the providers senior managers confirmed, although they had improved since the appointment of a new deputy manager. They said, “The appointment of a new deputy manager has provided additional leadership capacity and operational oversight.”