The Flowers Care Home 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 – 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 good. 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 at the service.

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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.
The service did not demonstrate a clear shared direction or positive culture. Staff were unable to articulate the provider’s vision and values, and they were not observed applying these values in practice during the assessment. There was little evidence of collaborative working between staff and managers, and staff reported that they did not feel listened to, supported to raise concerns, or encouraged to contribute to improvements.
The culture did not consistently promote inclusion, respect, or person-centred care. People from ethnic minority backgrounds were not consistently supported to communicate their needs or have their cultural preferences respected. Staff did not consistently recognise or respond to individual protected characteristics. People cared for in bed had very limited meaningful interaction, further demonstrating a culture in which individual needs and preferences were not prioritised.
Overall, the service lacked a positive, cohesive culture and shared direction. Staff morale was low, communication was poor, and people’s diverse needs and preferences were not consistently valued or embedded into practice. This created an environment where neither staff nor people using the service were consistently empowered, included, or supported.
 

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation.
Evidence showed the previous registered manager did not provide effective leadership, support, or oversight, which contributed to a decline in the quality of care. Following their voluntary deregistration, the provider failed to put adequate managerial oversight arrangements in place to ensure the safe and effective running of the service.
The provider was not consistently visible or present within the service either before or after the registered manager’s departure and did not provide the care manager or assistant manager with sufficient guidance, direction, or support. As a result, the care manager and assistant manager were required to manage the day-to-day operation of the service alongside their existing care duties, without competent and consistent leadership oversight.
Some staff told inspectors they felt pressurised to manage increasing workloads and were not supported by the registered manager during challenging periods. One staff member shared with us how they felt it was poorly managed but “it has got worse since November 2025.” Both staff and the provider confirmed the registered manager had not been visible within the service for several months prior to their deregistration.
Leadership within the service was not consistently capable or compassionate, and staff were not adequately supported, guided, or empowered to deliver safe, high-quality care.
 

People did not feel they could speak up and that their voice would be heard.
Staff did not feel confident to raise concerns or speak up about poor or unsafe practice. Some staff told inspectors they feared negative consequences if they raised concerns. One staff member reported being told if a manager became aware of a whistleblower, they would be dismissed.
This culture meant staff did not always report unsafe practices or concerns about the quality of care. As a result, opportunities to identify risks, address poor practice, and improve care were missed.
These findings demonstrate the service did not promote an open and transparent culture where staff felt safe, supported, and encouraged to raise concerns in the interests of people’s safety and wellbeing.
 

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.
Staff were not consistently included or treated as equal partners within the service. Care staff and senior staff carried out daily care tasks and completed required documentation; however, they were not supported or encouraged to feel empowered to contribute to service development, raise ideas, or suggest improvements. This limited staff engagement and inclusion in decision-making processes.
One staff member told inspectors they felt they had been treated unfairly and discriminated against following a period of absence from work. This raised concerns about how staff were supported and treated during times of vulnerability.
However, recruitment practices demonstrated an inclusive approach. The provider recruited from a diverse range of backgrounds, and staff confirmed that equality, diversity, and inclusion were respected during the recruitment process.
Overall, while recruitment practices promoted equality and diversity, the service did not consistently foster an inclusive working environment where all staff felt valued, supported, and empowered.
 

The provider did not have clear responsibilities, 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.
Governance systems were not effective in monitoring, assessing, or improving the quality and safety of care. Audits completed by the assistant manager and senior staff did not accurately reflect practice within the service and gave false assurance of compliance with policies and regulatory requirements.
A range of audits, including those relating to medicines management, safeguarding, equipment safety, infection prevention and control, care planning, dignity, maintenance, and the dining experience, reported appropriate systems and controls were in place. However, inspection findings consistently contradicted these assurances. For example, medicines were not managed safely, safeguarding controls were not implemented as stated, essential safety checks could not be evidenced, and people’s nutritional and care needs were not being met as described in audit records.
Despite these significant inaccuracies, all audits had been signed off as verified by the registered manager. This demonstrated a lack of effective oversight and scrutiny by senior leadership and a failure to identify and address risks in a timely way.
The provider did not ensure governance systems and quality assurance processes were implemented accurately or used effectively to drive improvement. As a result, standards were not maintained, risks were not mitigated, and the overall quality of care deteriorated prior to the inspection.
 

The provider did not consistently work effectively in partnership with other professionals and community services to support people’s care and wellbeing.
We found limited evidence of effective working relationships with some health professionals, including district nurses, and there were no clear links with local community groups that benefitted people living at the service.
However, records demonstrated general practitioners were involved in people’s care and treatment, and relatives told us the service had engaged with other professionals, including social workers and chiropodists, to meet specific health needs.
These findings show that while the service engaged with some professionals to meet people’s clinical needs, partnership working was not consistent or sufficiently developed to fully support people’s broader health, wellbeing, and community inclusion.
 

The provider did not demonstrate an effective learning culture, and there were no systems in place to ensure lessons were learned from incidents, near misses, or poor practice.
At our last assessment the service was rated good, however the provider had not taken effective action to maintain this rating or to sustain standards of care and safety.
Staff were not consistently monitoring people or reporting events, meaning that potential incidents were often unnoticed, unrecorded, and unaddressed.
Where accident or incident forms were completed, there was no evidence of follow-up checks or evaluation of the effectiveness of actions taken. Staff were unable to learn from previous events, and unsafe practices persisted, including people accessing bedrooms unsupervised, inadequate monitoring of people cared for in bed, and inconsistent application of safeguarding measures. These failures placed people at ongoing risk of harm and demonstrated that the service lacked mechanisms to review, learn from, and improve care practices.
The lack of a learning culture extended beyond incidents. Audits completed by the assistant manager and senior staff were inaccurate, giving false assurance that controls and practices were effective, but findings were not used to identify risks or implement improvements.
Staff were not supported through supervision, reflective practice, or training to develop their skills or address gaps in practice.
Overall, the provider did not create an environment where staff were encouraged, supported, or enabled to identify risks, share concerns, learn from practice, or innovate in care delivery. As a result, unsafe practices continued, and opportunities to improve outcomes, quality, and safety for people using the service were consistently missed.