Estherene 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 requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

At our last assessment, the service was in breach of legal regulation in relation to good governance. At this assessment, improvements had been made and the service was no longer in breach of regulation.

This service scored 75 (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 aims and objectives of the service were shared with the staff team, as well as the annual aims and objectives. The registered manager told us about the Bee theme in the service, which people using the service, relatives and staff were aware of. We saw staff, people and some relatives wearing bee themed clothing. In addition, some audits and monitoring tools also included the bee theme. For example, in the ‘Bee wise’ management audits, they referred to Bee aware, Bee productive, Bee proactive. These included monitoring of the service and information provided to staff in improvements required. Monthly ‘Bee learning’ documents identified lessons learned and the requirements of staff. A staff member told us they were kept updated with any changes and actions they needed to take, however, they felt this placed a lot of pressure on the care staff team.

Each month, staff were required to read and sign that they had read a policy and procedure. This included in September 2026 sickness absence, and in August 2026 dignity, respect and choice. There was also a service process file for staff to read, this included subjects such as medicines management, falls, call bell response times, choking protocol, and recording skin tears, bruises, red marks and pressure areas.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The registered manager told us how the morale in the service had improved since our last assessment. Sickness levels were reducing due to the monitoring and improvements in the service. A staff member told us, “We are like one big friendly family, get on well with each other.” Another staff member said, “It is improving here so much, I am very happy working here.” Another staff member told us they felt communication could be improved, when there had been changes to the staffing rota.

The registered manager told us how they were further developing staff roles in the service, this included in staff acting as champions in a specific area and empowering senior staff to work on care plans and run the shifts, with training and guidance. Care plans were being printed by the senior team and care staff advised to read them.

People and relatives told us they felt the registered manager and the deputy manager were approachable and visible. A relative told us, “I pass by the office most days when I visit and would say the manager and assistant manager are very visible when I am in the home.” Another relative said, “Management are really good, we are one happy family.”

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

There was a whistleblowing procedure in place, which staff were aware of, and said they would report any concerns and would be listened to. The registered manager told us how they had an ‘open door’ and would speak with staff if they wanted to raise any concerns.

Minutes of staff meetings showed staff were asked for their views and suggestions about the service. The registered manager told us how staff were empowered to implement their suggestions to improve the service. Staff were also asked for feedback about the service in surveys. We saw actions were taken as a result of staff feedback, this included changing the electronic learning system when staff had said it was difficult to use.

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. This included planning the rota to support staff to participate in their faith and cultural festivals.

The company had guidelines which staff signed to say they will communicate with residents and all staff in English and only use their own language on their breaks. However, a person told us sometimes staff spoke with each other in their own language. We fed this back to the management team, and they confirmed they monitored this.

A member of the management team told us how a senior meeting was planned with both the day and night staff, this helped the relationships within the staff team. A staff member said, “I feel very supported by colleagues, we all support each other and cover, feels like family, we are close, it is a safe space.”

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There was a range of audits and governance systems in place which assisted the management team to identify shortfalls and take action to address them. These included audits undertaken by the management team and also by the provider’s representative. Audits included medicines, care plans, infection control and health and safety.

Monitoring systems included weekly checks on fluids, constipation, falls, staff sickness, personal care, medicines, call bell response times and incidents and accidents, where improvements were noted, staff were advised of actions to take. These checks included calculations, for example, of fluids, and how many showers people had.

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 registered manager told us they worked with other professionals and accessed services in the community, such as veteran groups. We saw correspondence from the registered manager to a school and a local football club to build relationships, with a view to have visits to people in the service. The service had participated in and won an award for the local area ‘in bloom’ annual display of flowers and plants.

To keep up to date with changes in care and good practice guidance, the registered manager attended conferences and meetings held by industry recognised partners. The staff meeting minutes in April 2026 stated the registered manager had visited a veteran friendly care home to gain ideas.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

There was an action plan in place, which identified how the service planned to continuously improve. The registered manager discussed the ongoing improvements in the service.

The service was using an electronic system, with people’s consent, which detected, for examples unusual sounds or movement which needed staff to check on people. This reduced the need to physically check on people at night, when they had asked not to be disturbed. The registered manager told us it had contributed to the reduction of falls. The provider were finalists in a two national care awards due to the use of the innovative system and the provision of dignity in care.