Archived: The White House

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 inadequate. At this assessment the rating has remained 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 poor governance and leadership and notifications not being sent to the CQC where required.

This service scored 25 (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 provider and manager had not developed a clear vision, strategy or set of values, aims and aspirations for the service which staff knew about and followed. Leaders did not demonstrate how they supported staff to place people at the heart of the service, protect them from harm and enable them to live their best life. There was a closed culture at the service: this had a detrimental impact on every aspect of people’s lives, and created an environment where harm, and risk of harm to people occurred. The culture of the home was not based on the promotion of learning and improvement. There was a lack of observations of staff practices to ensure staff received the support and feedback about their performance to help drive improvements in the home. Throughout the inspection, the manager remained in their office aside from when we asked to speak with them.

We also found that people’s care notes could be not solely relied upon to show what care had been provided. For example, we observed 3 people were either not offered a drink in the middle of the morning or the drink was left with them and not drunk. However, their care plans recorded that all 3 had their drink. This lack of accurate recording meant that leaders could not be assured that people received sufficient hydration.

Reviews of people’s care plans had not ensured a fully inclusive and collaborative process of care plan development. The provider had not ensured staff had completed core, or specific training in accordance with people’s individual needs to promote equality, diversity, inclusion and engagement.

We noted that the clothing belonging to previous residents had been stored in an undignified way in one of the empty bedrooms. It is important to respect the dignity of previous residents by handling their personal belongings in a way that acknowledges their worth.

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. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The manager and provider failed to have the skills, knowledge and experience to provide support and guidance to the staff team. The provider failed to maintain oversight of the quality of care being provided therefore sufficient improvements had not been made since our previous inspection. The provider and manager failed to demonstrate they led by example with promoting inclusive behaviours. They had not always acted with honesty and integrity as they had not shared information of concern with partner agencies.

We found information given to us by the manager was not always accurate. For example, the manager told us an external professional undertook activities for 2-3 hours every Monday. We heard this professional advise a person that they were only there for 45 minutes every Monday and we saw this was the case on the day of the inspection. The manager told us, “I was under the impression that he's there two hours. He comes around 9.30 and he leaves around 11.30.” However, when we followed up with the professional, they advised they were only ever there for a maximum of 45 minutes.

There were missed opportunities for leaders to ensure that the service was safe and effective. For example, incidents of a safeguarding nature were not being appropriately recorded by staff. Therefore, leaders did not have the information they needed to ensure effective oversight.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Systems for identifying, capturing, and managing organisational risks were ineffective and did not highlight the concerns we found despite the manager undertaken audits. For example, leaders did not always ensure medicines were managed safely or that associated records complied with guidance. Regulatory requirements to notify CQC of notifiable events were not met because information was recorded incorrectly. We were not assured that the manager or provider had effective oversight of the service. Management and staff did not demonstrate an understanding of good quality assurance principles, and the service lacked clear drivers for improvement. The manager told us that the provider or any representative did not undertake any audits of the service.

The manager also lacked an understanding and knowledge of people’s needs. For example, they told us 3 people were permanently cared for in bed. However, only 1 person was cared for in bed, the other 2 spent every morning sat in the lounge. The manager told us that people that were on regular and ‘as and when’ laxative were not at risk of constipation. Despite using laxatives, older people often experience chronic constipation due to low mobility, low fibre diets, reduced fluid intake, and certain medications.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

Referrals to other agencies were not always completed timeously due to poor recording practices. As noted in this report, staff failed to record where 1 person was unwell and failed to raise these concerns with a visiting professional. We noted from incident reports that people sustained skin injuries which had not been reported to the Tissue Viability Nurse (TVN) who told us these should have referred to them. We also found the GP had not been informed when a person had been admitted to hospital. Where professionals had been contacted, people’s care records were not always updated with the guidance provided or lacked recording of any professional being contacted.

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

Systems and processes were applied inconsistently, with no clear audit schedule or effective quality assurance in place. The provider and manager did not demonstrate oversight or implement action plans, despite repeated concerns raised during previous inspections. This reflected a continued lack of accountability and improvement. The provider and manager did not fully understand the principles of good quality assurance and were unable to consistently identify areas for improvement. This resulted in missed opportunities to address safety shortfalls. There was little evidence of learning, reflective practice, or service improvement. Information to support performance monitoring and decision-making was unreliable or not collected. For example, incidents and accidents were not always recorded or reviewed effectively to identify patterns or triggers requiring action. We saw no evidence of learning from incidents in staff meetings or supervisions.

We saw in multiple care plans that reviews had been undertaken by external professionals prior to December 2025 where they had highlighted gaps. These comments by the professionals remained in the care plans and no action had been taken by the manager to address this.