Provence 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. This is the first assessment for this service. This key question has been rated 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 service was in breach of legal regulation in relation to governance at the service.

This service scored 57 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The service demonstrated a generally positive culture with shared values that were understood by most staff. The provider had developed a set of values that were visible in staff interactions and reflected in how people described their care. Several people told us staff were “very kind” and “lovely”. Relatives described the home as having “a really lovely community” with staff who “try to be inclusive”. Staff and people often spoke warmly about the sense of community and belonging.

Staff told us they cared about the quality of care they provided, with one saying, “We are here because we care.” This was reflected in many kind interactions observed across the home. People described feeling safe and valued, and several relatives told us staff took time to get to know people’s histories and preferences. Staff across domestic, care and kitchen roles spoke positively about working in the home and said they enjoyed spending time with residents.

However, the culture was still developing. Although most staff felt included, a few said they did not always feel listened to when raising concerns about workload or staffing. The provider had recognised gaps in managerial oversight and work was underway to rebuild consistency.

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, and they did not always demonstrate open and transparent leadership.

Leadership was inconsistent, and staff described a lack of visible and effective managerial presence across the service. Several staff told us leaders were approachable in principle but were not always present in the units when needed. One staff member reported, “[The Registered Manager] does not usually come onto the units.” A relative echoed this and said they rarely saw the registered manager. Other staff members told us decisions were sometimes made without input from those directly providing care.

Staff told us they wanted more hands‑on support, especially when the service was short-staffed. Some seniors were new to their roles and still developing confidence with oversight tasks, which meant staff were not always guided effectively. However, there were examples of compassionate leadership. The provider had acted quickly when feedback was shared during the inspection and had begun to review processes. They also encouraged appreciation of staff achievements and celebrated staff of the month. Staff who had personal difficulties described supportive responses from leaders.

People did not always feel they could speak up and that their voice would be heard. The culture of speaking up was not fully embedded or consistently effective.

Staff had mixed confidence in raising concerns. Some staff felt able to speak openly and said managers were approachable. Others described occasions when concerns about staffing or practice “did not lead to change” or were not acted upon promptly.

There were processes for whistleblowing, and staff were aware of them. However, several staff told us they were unsure whether their feedback would be acted upon or whether they would receive a response. One said, “Nothing happens when we say anything.”

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 service promoted inclusive values and supported staff with flexible working where possible. Staff confirmed they had equal access to training and development opportunities, and examples included support for staff completing additional courses. Some staff had been supported with flexible arrangements, and leaders were described as understanding around personal circumstances.

People using the service also experienced respectful and individualised support. Staff recognised people’s cultural needs and personal histories, and relatives described staff as treating people with dignity and respect. One relative said staff “know them and treat them as an individual.”

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 and did not ensure safe, consistent or well‑coordinated care. The registered manager acknowledged that oversight across audits, staffing and care records was “disjointed”. This was reflected throughout the inspection.

Audit processes were incomplete and not always accurate. For example, accident and incident analysis contained miscounts and errors, and managers did not always identify these before sign‑off. Some audits were being completed for the first time by staff who had not been trained to do them. Important areas, such as simulated fire drills, had not taken place in line with best practice.

Care records were also inconsistent. DoLS records did not always reflect up‑to‑date information, and several people’s restrictions had expired without evidence of timely reapplication. Some risk assessments lacked essential detail, such as how people who could not use call bells would summon help. Some care plans contained contradictions, outdated information or missing best‑interest documentation.

Oversight of staffing was poor. Staff were frequently moved between the care home and the provider’s domiciliary care service without clear planning, resulting in shortages on units. Staff described days when essential care tasks, such as personal care and repositioning, were missed due to insufficient staffing. Leaders did not consistently record or review these gaps, and staff said rotas were not updated promptly.

Although the provider was committed to improvement and had started new processes, governance was not yet robust. Key systems required significant strengthening to ensure sustained safety, quality and reliability.

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 service worked positively with external partners and involved families in people’s care. Health professionals described good collaboration and said staff were well prepared for clinical visits. One GP practice reported staff were “well prepared” and raised concerns appropriately.

There was evidence of strong working relationships with organisations such as Dementia Forward, who had provided training and support. Activities staff also coordinated with external professionals, such as the music therapist, who praised the home for being “welcoming and supportive”.

Relatives felt involved and said staff kept them updated, and some said they were invited to give feedback informally. Staff supported people to maintain community links, such as attending local clubs or going on outings.

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 service was in the early stages of developing a learning culture. Leaders had begun to respond to inspection feedback, and some improvements were already underway. Staff were positive about new ideas, such as the “resident of the day” approach and enhanced dining experience observations.

However, learning from incidents was not consistent. Several staff described repeated staffing issues that had not led to changes. Records did not always show lessons learned or follow-up. Similarly, systems such as call‑bell monitoring were unreliable, and issues with inaccurate times had not been resolved prior to the inspection.

Innovation was emerging but not embedded. For example, a new digital monitoring system was being developed for nurse call data and actions, but it was too early to demonstrate impact. Staff champions in areas such as end‑of‑life care were keen to develop their skills, and there were examples of creative activity‑based practice, such as sound baths and community outings.

Although the provider had been responsive to feedback and there was some momentum for improvement, the service had not yet embedded learning or demonstrated sustained, proactive innovation.