Royal Care Home

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 inadequate. This meant there were widespread and significant shortfalls in service 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 the good governance of the service.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The services vision, strategy and culture was not always based on equity, equality and human rights, inclusion, and engagement.

Although staff spoke about them providing people with good care, they raised various concerns about the management with us, which showed a potential culture issue within the service as detailed in this report. Various policies were in place to support an open culture, and the registered manager told us they have an open-door policy, but staff did not feel they were treated equally.

The service did not have inclusive leaders at all levels who embodied the culture and values of their workforce and organisation. Leaders at all levels did not lead effectively, and they did not always do so with integrity.

Staff shared concerns about the management of the home. Although we found the management team mostly approachable throughout our inspection, due to the concerns we have identified, further improvement is needed to ensure the management team are capable, compassionate and inclusive leaders. Although the management had identified some of the issues we found, they had not always been able to swiftly drive improvement.

Staff did not always feel that their voice would be heard.

Although the provider had a whistleblowing policy available to staff and staff were able to raise any concerns in team meetings, staff told us they were able to speak up, but that action was not always promptly taken. One staff member said, “I have raised issues about staff not doing things, it hasn't been acted on straight away.”

The service did not work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Although an equality and diversity policy was in place which set out how they support equality and diversity and the service employed a diverse range of staff, staff told us they did not feel they were treated equally.

The service 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.

Although multiple audits and oversight tools were in place they did always not identify the issues we found during our inspection. Some audits needed to be more robust, whilst some audits needed to be implemented to drive improvement. Although some audits were identifying issues, improvement was not always being driven.

The home currently has 2 managers that are registered with CQC, however, one of these managers left the service in 2023 and this has not been followed up by the provider. Various policies were in place, but not all policies were being followed. Provider oversight was not robust. An annual director monitoring checklist was completed in April 2025 and did not identify a number of issues we have identified. The nominated individual visited the home to offer support and the registered manager told us the directors were on hand should they need support. Monthly meetings were taking place between the providers and the registered manager but notes were not robust and we could not determine if concerns at the home had been fed back, for example there had been issues with cleaning records/cleanliness recorded since May 2025, however this is not documented as part of these calls.

Some records were not always appropriately or accurately completed. The service put together an action plan following the last CQC inspection – multiple areas of this action plan had not been met or sustained. Following the concerns identified during our inspection, the registered manager has implemented a senior’s checklist to try and drive improvement in multiple areas.

The service did not always support people to access the community, and improvement was needed to work collaboratively with other organisations to drive and sustain improvement.

People did not feel they were supported to attend or engage with any local community or service user groups. Feedback from partners was not always positive. One professional told us they were “Unsure” if they feel the service works in a collaborate and joined-up way with their organisation to support service development.

We saw examples of the service working with various organisations and people could gain access to advocates when needed.

The service did not focus on driving consistent continuous learning, innovation and improvement across the organisation.

Staff did not feel that improvement was happening at any pace and that there was still a long way to go. Their comments included, “Things go a long time without being done. (It is) Better than it was but still needs improving.” And “There have been changes but things are taking a long time.” The home had failed to drive all the necessary improvements despite CQC’s previous ratings and enforcement actions and at this inspection we found a number of similar concerns to that which we found during our last inspection.

As audits were not always identifying the issues we found and in cases where some audits did identify issues, improvement had not always been made, this made it difficult to understand how the home consistently drove improvement, identified concerns and how they consistently learned and acted upon them.