Gibson's Lodge Limited

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

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 good. At this assessment the rating has changed to requires improvement.

Requires improvement: This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was in breach of legal regulation in relation to governance.

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 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 changes made on 1 February 2026 to the management team, were not clearly explained to staff. Some staff told us they were not kept informed or involved, which caused uncertainty. While some staff spoke positively about their work and commitment to residents, others felt less supported or valued. One staff member said, “We are here for our residents, but we are not always informed.”

The lack of clear communication around these changes affected how confident and supported some staff felt. Although staff continued to work hard for residents, clearer communication and better engagement would help strengthen trust, improve morale and support ongoing service improvement.

Staff described mixed experiences of the culture. While some staff said they enjoyed their roles and felt committed to people’s care, others told us they did not feel valued or listened to.

The provider did not consistently promote a culture of transparency, inclusion or engagement. Leaders did not ensure all staff understood the direction of the service or felt involved in its development.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

Leaders did not consistently demonstrate the skills, knowledge or oversight required to manage the service effectively.

Managers failed to identify and address significant risks in a timely way. Issues relating to medicines management, consent and care planning were not identified or addressed until raised during this assessment.

Managers did not ensure staff had clear, accurate and up-to-date guidance to support people safely. This resulted in inconsistent care delivery and increased risks to people.

Although managers showed a willingness to improve and engaged positively during the assessment, this did not translate into effective oversight or sustained improvements.

A new deputy manager had recently started in post and had begun reviewing care records. However, improvements were not embedded, and the impact could not yet be demonstrated.

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

Staff told us they felt comfortable speaking with registered manager and would raise concerns if needed. They said they felt supported. Staff told us that they felt able to raise concerns with the manager and One staff member commented, “You can go to any of the nurses with any problems.” Another staff told us, “I would raise any concerns with the manager and would feel supported.”

The provider had policies and procedures in place to support whistleblowing and raising concerns.

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 were from a range of cultural and professional backgrounds worked at the service. Staff told us they felt welcomed and received good support when settling into their role.

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 did not operate effective governance systems to ensure the safety and quality of the service. The provider had managerial oversight audit systems in place; however, these failed to identify the concerns we found during the assessment. These included issues relating to care planning, risk management, medicines management and recruitment practices. Records were not consistently accurate, complete or up to date. Care plans and risk assessments did not provide staff with sufficient guidance to manage people’s needs safely for example we did not see clear guidance on people with complex health conditions such as Parkinson’s, diabetes etc.

The provider did not maintain effective oversight of medicines management. Systems for monitoring safe administration and record keeping were not robust.

The provider did not ensure safe recruitment processes were followed.

Overall, governance systems were ineffective in identifying risks and driving improvement. This meant the provider could not demonstrate effective oversight of the service or ensure positive outcomes for people.

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 provider worked in partnership with external professionals to support people’s care.

Staff liaised with healthcare professionals and arranged visits and interventions when required. This supported people to access appropriate care and treatment.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider did not ensure continuous learning and improvement across the service. Audit systems and monitoring processes failed to identify the concerns highlighted during this assessment. This demonstrated that systems to evaluate and improve the quality and safety of care were not effective.

The provider did not ensure staff had regular opportunities to reflect on practice. Supervision and team meetings were not consistently held, which limited opportunities for shared learning and improvement.

Although managers were open to feedback and demonstrated a willingness to improve, this had not resulted in sustained or embedded improvements at the time of the assessment.