Neptune 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 good. At this assessment the rating has changed to 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 regulations in relation to governance at the service and notifying CQC of important events.

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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The provider and management team were passionate about the service and wanted to ensure people had good quality care and improved outcomes. However, they had not always recognised that people had not been treated with equity in relation to the language and terminology used within care plans.

Staff gave positive feedback about the culture of the service. Staff reported a positive open culture where they felt empowered to raise any concerns or make suggestions. Comments included, “There is a good culture at the service, it’s really good recently, not much has changed with the new management on nights. The whole team is better”, “There is a really good team culture. There is a big divide in ages and there are younger staff and older staff, everyone is fun” and “I think the morale and culture is really good, I think it is amazing, all the staff get on, such a good team.”

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 management team knew people well and were passionate about making sure people received good quality care. There was a clear management structure in place with 2 registered managers and a deputy manager. The service also had care staff to provide care and support as well as a cook and a housekeeper. Staff understood their responsibilities to meet regulatory requirements. The registered managers told us they were well supported by the provider. Staff told us the registered managers were supportive and approachable and were confident in reporting any concerns. Relatives told us the registered managers were approachable. A relative said, “The management provide an open door policy, we can contact them whenever we need to, no major issues have been raised, but if one arose we would be confident that it would be dealt with in a timely and professional manner.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a whistle blowing policy in place; however, the policy provided no contact details and information of who staff should report concerns to. Despite this, staff felt confident in reporting to managers and staff knew they could report outside of the organisation. A staff member said, “I would feel confident to whistle blow if I needed to, I don’t have any safeguarding concerns at the moment regarding anyone.”

Staff confirmed they previously had staff meetings and were encouraged to contribute. Staff told us no staff meetings had taken place since the change in management. Staff told us they were encouraged to voice their ideas for improvements and any concerns.

The service had received no complaints within the last year. Relatives told us, “I have no cause to make a complaint, but the managers seem to be approachable”, “I have no concerns or complaints” and “I have had no real cause for complaint over the last few years, I am confident that if the need arose management would deal with any issues promptly and keep me informed of any outcomes.”

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.

Staff told us they felt well supported and they felt communication was good. The registered managers told us there was flexible working, around childcare and religious needs. Staff said, “We get good support” and “The managers are considerate of wellbeing, if I had any issues they would definitely help me.”

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.

There was a lack of provider and registered manager oversight of the service. Audits and checks were not robust and had not identified the issues we found at the assessment. Records were inconsistent and conflicted in places. Audits had been carried out of daily records, care plans, finances, staff communication, handover, medicines, accident and incidents, health and safety, fire, PPE, COSHH, (Control of Substances Hazardous to Health) and infection control. The audits were not always robust enough to highlight and manage shortfalls and areas for improvement in the service. For example, medicines audits had not identified the issues with recording and temperature checks of the medicines room. Care plan checks had not identified that care plans did not provide staff with guidance on how to provide care and support and the terminology used within the care plans was derogatory.

The provider had policies in place which did not provide adequate information and guidance for staff or managers. They had not been updated for many years and were not fit for purpose.

Services providing health and social care to people are required to inform the CQC of important events that happen in the service. This is so we can check that appropriate action has been taken. We were not always assured that incidents had been appropriately reported. CQC had not been notified of safeguarding incidents and serious injuries to people which had occurred and DoLS authorisations.

Where audits had identified actions, actions had been recorded and the management team had signed off items that had been addressed, such as the registered managers had identified some audits and checks required amending and they had put together a revised audit tool for use in 2026.

Services that have received a rating are required to publish their rating on their website and within the service. The provider had displayed their rating in line with the regulations.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. The management team and provider had not signed up to local authority forums for providers and registered managers or Skills for Care support to drive improvements and good practice.

However, all staff worked with visiting health and social care professionals. Staff explained how they welcomed visitors. We observed some people were supported to get out into the community to access voluntary work and appointments. The registered managers told us that people were well known in the local area and utilised the local amenities such as shops, snooker hall and amusement arcades. People and their relatives told us about support to attend concerts, football matches, national dog shows and other activities which people enjoyed.

The service produced a regular newsletter which showed people and their relatives news about the service. A relative said, “I really love getting ‘Neptune News’, it keeps me up to date with what all of the residents have been doing, in addition to detailing up and coming events and parties that might be of interest to me.”

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. Since the last inspection, the quality of the service had declined, systems to learn from incidents and accidents were not embedded. The registered managers told us since the assessment they have put together an action plan and are encouraging and supporting staff to develop to support improvement in the service.

The provider and registered managers told us they had reviewed the feedback we gave them as part of the onsite and offsite assessment process and valued this. They were using the feedback to make improvements to the service and to put systems in place to embed the changes. Areas discussed at the assessment site visit were added to the action plan for the organisation in a timely manner and the registered managers updated CQC on the progress of these actions.