Pittsmead Grange Care Home

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• 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 newly registered 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 good governance and oversight at the service.

This service scored 54 (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 always have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. The provider was in the process of embedding and strengthening its vision, strategy and culture following leadership changes.

Whilst the provider and registered manager was working to embed a positive culture within the service, this required time to embed lessons learnt into staff practice. We received mixed feedback from staff about the culture within the service with most commenting it was improving. We looked at the staff survey, ‘your voice’ conducted in January 2026. We noted concerns raised related to specific individuals and staffing levels within the service. We met with the providers human resources representative who visited the service to hold a staff surgery in response to the survey. The registered manager told us this provided staff with the opportunity to share their views and discuss changes being made.

Daily ‘stand-up’ meetings were held with senior staff to discuss the running of the service. We attended a stand-up meeting. The meeting was led by the registered manager, also in attendance were the housekeeper, senior care staff, the home administrator, chef and the activities coordinator. Issues discussed included residents of the day, people’s health conditions, hospital admissions or health visitors to the service, new admissions to the service, staff absence, training, policy of the day, the menu for the day and any planned social activities. The registered manager reminded senior staff to feedback information from the meeting to staff on their units, for example all staff were required to read and sign policy of the day ‘end of life’ and staff having access to a confidential helpline where staff could speak with a health professional at any time.

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.

There was a lack of robust management and oversight at the service. Management had a clear lack of understanding and knowledge ensuring robust monitoring, oversight and learning was in place and embedded at the service. Management failed to identify concerns and areas for improvement at the service, and audit and governance systems in place were not robust and effective.

Staff told us there was a 24 hour on-call number where they could contact managers if they needed any advice or support. Staff were positive about the support they received from the registered manager. One staff member told us, “If I go the registered manager, he always tries support me.” Another staff member said, “The manager is approachable, he is interested in helping me with my personal development and career growth.”

People felt they could speak up and their voice would be heard. Staff told us there were effective systems in place for them to raise any concerns and they felt confident action would be taken if they used them. A staff member told us, “We have a good programme around this. We have a speak up champion. If I had an issue, I would first go to management but then escalate if needs be. I am also aware of Whistle blowing, [provider] has an anonymous line. I would then go to CQC.”

We met with the providers human resources who visited the service to hold a staff surgery in response to the results of the staff survey. The registered manager told us this provided staff with the opportunity to share their views and discuss changes being made at the service. A staff member told us, “I attend team meetings. I feel listened to and valued.”

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 provider supported staff to feel included and treated them with equity, taking account of their individual needs. We spoke with the regional director who told us they celebrated a cultural day in October 2025 where all staff embraced equality and diversity, and this was an excellent occasion where they celebrated how diverse the staff team were. Staff wore traditional clothing and brought in homemade traditional food for staff to try and taste.

The provider did not always have clear systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. There were failings in leadership and governance of the service. Systems to monitor the quality and safety of the service were not always effective. The provider had identified the need to improve and strengthen their systems and the documentation of personalised information through its internal governance arrangements, and this was in progress at the time of our assessment.

There was a lack of robust and effective oversight and management of accidents and incidents. Accident and incident records were not always completed in a timely manner and there was a lack of evidence to show that the cause of accidents and incidents had been consistently investigated. We observed staffing levels within the service appeared minimal and feedback from people and staff demonstrated this with people telling us they waited long periods at times for staff support. Call bell response times were monitored by the registered manager. The management and administration of medicines was not robust. Multiple medicines errors were reported, and these were subject to local authority safeguarding enquiries. Oversight of medicine management within the service was not robust and records showed delays in reporting medicines errors, delays in assessing people’s well-being after missed medication, and a failure to ensure medicines administration charts were updated to record missed doses. There was a lack of robust oversight and management of people’s care records, support plans and risk assessments to ensure they safely identified, assessed and documented people’s needs, risks and wishes.Care records did not always document people’s diverse needs and wishes relating to any protected characteristics in line with the Equality Act 2010.There was a lack of management and effective oversight of the management and application of the Mental Capacity Act 2005 Codes of Practice and the Deprivation of Liberty Safeguards. Concerns were found in relation to historic DoLS applications, but we found that improvements to the timeliness of DoLS applications were underway. Delays in managing Deprivation of Liberty Safeguards related to historic applications and we noted that improvements were in progress.

The registered manager and provider listened to our concerns and started to make changes during our assessment. The provider had identified the need to improve and strengthen documentation of personalised information through its internal governance arrangements, and an action plan was in place to address these issues.

The provider did not always ensure the registered manager understood their duty to collaborate and work in partnership, so services work seamlessly for people. The registered manager did not always share information and learning with partners or collaborate for improvement.

Records demonstrated the registered manager did not fully understand their duty to collaborate with other services and professionals to ensure continuity in people’s care and to achieve best outcomes. For example, some people had not been appropriately assessed when they lacked capacity to consent to aspects of their care. Some care records had contradictory information about people’s capacity for specific decisions. This meant staff did not always have clear and accurate guidance on how to best to support people. Where people needed to be deprived of their liberty to keep them safe, we saw that the registered manager and provider had not always ensured that a deprivation of liberty safeguard (DoLS) authorisation was applied for promptly through the relevant local authority. This meant some people could unlawfully be restricted.

The regional manager told us the service had links with a local church which people could attend monthly coffee and cake mornings, and the chef provided cakes freshly made. The service held weekly ‘knit and natter’ groups with the local community, who were providing blankets for a local hospital baby unit to support them and families. The service held a monthly carers café for carer’s who care for people at home. They offered them complimentary head and shoulder massages from their local beauty therapist. The service also had links with the ‘Chelsea pensioners’ who had visited the service to give talks and had invited some people for day trips to the ‘Chelsea hospital’.

The provider and registered manager 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 registered manager did not always adhere to policies and safe practice to focus on and help drive continuous learning and improvement from audits and quality governance systems.

The management team provided us with an action plan of identified areas of concerns and the service improvements they had started to implement. The management team welcomed our feedback and had started to take action to address the issues identified during our assessment. For example, an increase in staffing levels, support from the providers clinical development nurses to address medicines management and practice, and support from the provider’s human resources team to work on improving the culture and staff moral within the service.