Aston Manor EMI 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 assessment we rated this key question Requires Improvement. At this assessment 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 good governance.

This service scored 32 (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. They did not always understand the challenges and the needs of people and their communities. The provider did not have robust auditing systems in place to enable them to monitor and improve as well as identify, mitigate and manage risks. The management team did not have clear oversight of the service. Relatives we spoke with were not aware or had not attended any meetings to provide feedback. Relatives could not recall receiving any newsletters or surveys. Not all people we spoke to knew who the registered manager was. Staff we spoke with said that they did not have regular team meetings.

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. There were some systems in place to capture the views of staff, however the provider was not demonstrating how they were listening and responding to staff. Staff feedback was mixed in relation to regular supportive supervision. One comment included, “I think my last one was around 6 months ago. I think we have them every year or so.” Leadership and management at the service was not effective. The provider had failed to act on the issues impacting the service in a timely manner.

People did not always feel they could speak up and that their voice would be heard. The service did not have proper systems in place to formally capture the views of staff, such systems needed be operated in an open and transparent way. The provider needed to improve their processes to demonstrate how they are listening and responding to staff. Relatives were not actively invited or supported to share feedback.

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. The service had an equality and diversity policy in place. Management told us staff were trained in equality and diversity. However, some staff had not completed up-to-date equality and diversity training. One staff member told us they could do with more training on end-of-life care, and another said they didn’t always feel there were development opportunities such as additional more in-depth training.

The provider did not have clear responsibilities for staff, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The oversight and monitoring of the service had not been effective in identifying and addressing the safety concerns found during this assessment. The concerns identified with risks linked to people’s care, maintenance, fire safety and equipment at the service had not been previously identified by the provider’s quality assurance checks. The service failed to ensure arrangements in place were adequate and safe. During this assessment, we identified many areas where the service fell short of the expected standards of care. Many of these shortfalls were due to the significant lack of oversight and monitoring of the service by the registered manager and provider.

They did not always share information and learning with partners or collaborate for improvement. We found people required a referral to be completed to external health professionals for a review of their care, but this had not been carried out. The registered manager had identified this was an issue but required action had not been taken until prompted by the assessment team. Although there was a management structure in place, there was a lack of leadership and accountability in the running of the day-to-day of the service.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. There was a long history of non-compliance at the service. We have carried out 8 inspections between 4 November 2015 and 23 July 2025 and the service had been rated inadequate on 3 occasions and requires improvement on 4 occasions. Whilst the service had put some measures in place to improve they had failed to maintain and embed these, and this impacted the quality of the service people received over time. By failing to improve, people were at risk of harm and of not receiving the quality of care they require to meet their individual needs.