Witnesham Nursing 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 inspection we rated this key question good. At this inspection 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 regulation in relation to governance at the service.

This service scored 61 (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 was undergoing a period of organisational transition, and the registered manager and provider recognised that some areas required improvement.

Feedback indicated there had been challenges embedding improvements and achieving consistency across the staff team with some staff reporting some resistance to change when concerns or areas for improvement were identified. Despite this, staff spoke positively about working at the service and consistently expressed a commitment to providing good care. One staff member told us, “The service is committed to providing good care and supporting the people who live there. Staff care about the people they look after and want them to have a good quality of life. There are always areas that can be improved, but I feel staff and managers should continue to work together, listen to feedback and focus on providing safe, personalised and compassionate care.”

Leaders were open and transparent about the challenges facing the service and recognised where improvements were required. This openness provided a foundation for learning and development. However, further work was needed to strengthen the culture, ensure staff consistently embraced improvement initiatives and promote a shared approach to delivering high-quality, safe and person-centred care.

Leaders had an understanding of many aspects of the service; however, opportunities were identified to further strengthen oversight and understanding across all areas of care, treatment and support

People, relatives and staff spoke positively about the leadership of the service and described the registered manager as approachable and supportive. Leaders were open and transparent throughout this inspection and demonstrated an understanding of the areas requiring improvement.

The provider acknowledged that some of the concerns identified during the inspection had arisen during a period of significant organisational change, including vacancies in key roles responsible for clinical governance and maintenance oversight. However, these shortfalls occurred while a leadership structure remained in place, and the provider retained responsibility for ensuring effective oversight of the service. The provider recognised where governance arrangements had not been fully embedded and had implemented an improvement programme following the acquisition of the home in February 2026. While leaders demonstrated a willingness to learn, reflect and drive improvement, further work was needed to ensure governance systems were consistently effective and resulted in sustained improvements to people's care, safety and outcomes.

We spent time with members of the leadership team and observed positive interactions with people. They demonstrated a good understanding of people's individual needs and supported them in a kind, compassionate and respectful manner. This helped to promote people's well-being and ensure care was delivered in a person-centred way.

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

People and their relatives felt that the management team were approachable and felt confident that concerns would be dealt with professionally. Opportunities to give feedback and make suggestions for improvement were ongoing at the service.

The provider had a policy in place to ensure staff were able to raise any concerns. Staff were aware of the policy and mostly described feeling comfortable to raise any concerns. One staff member said, “Managers are visible and approachable, and they lead by example by being involved in the day-to-day running of the service.”

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 valued, respected and treated fairly within the workplace. Most staff had completed equality and diversity training, demonstrating the provider's commitment to promoting an inclusive culture. This helped staff to understand and respect people's individual backgrounds, characteristics and experiences, supporting the delivery of person-centred care and helping to create a positive environment for both people using the service and staff.

The provider had governance and oversight mechanisms in place, although these were not always consistently effective in driving improvement and assuring quality.

Governance and oversight arrangements were not always effective in identifying, monitoring and addressing risks to people's health, safety and well-being. We identified concerns relating to care planning, risk management, medicines management, record keeping and compliance with the Mental Capacity Act, which meant the provider could not always demonstrate that people consistently received safe, high-quality care.

The registered manager was open and transparent about the challenges facing the service. They told us a recent mock inspection had identified a number of areas requiring improvement and that an action plan was in place to address these. The registered manager explained that a prolonged period of organisational change, including the transfer of ownership and operational responsibilities, had impacted their ability to maintain oversight of all aspects of the service. They acknowledged the service was “not where we need to be” and were aware that improvements were required.

The provider had also sought assurance through external quality monitoring processes, including a recent local authority health check, which identified similar areas for development. This demonstrated that many of the concerns found during our assessment were already known to the provider. The management team were transparent with us about these shortfalls and took immediate steps to begin addressing concerns identified during the assessment. However, the required improvements were not yet sufficiently embedded or sustained to demonstrate effective governance or to consistently drive improvements in outcomes for people using the service.

Relatives spoke positively about how the service worked with external professionals to support people's health and well-being. Effective partnership working helped to ensure people could access specialist advice and support when needed, contributing to positive outcomes.

People were also encouraged and supported to remain involved in their local community, including taking part in visits and outings to local places. This helped people to maintain social connections, reduce the risk of isolation and support their overall well-being.

The provider had begun to identify opportunities for learning and improvement; however, these were not yet always embedded consistently across the service.

Although the provider had a service improvement plan in place, quality assurance systems had not always been used effectively to identify and address concerns in a timely way. As a result, some of the shortfalls identified during this inspection had not been recognised by the provider until they were highlighted through an external audit and this inspection. This limited the provider's ability to drive continuous improvement and provide assurance that risks were being identified and addressed at the earliest opportunity.

The provider was receptive to feedback and demonstrated a commitment to improving the quality of care. This reflected findings from an independent review they had commissioned. Although action had been taken and progress was evident, further time was required for these improvements to become fully established and consistently embedded in practice.Following feedback during the inspection, immediate action was taken to address identified risks and reduce the potential impact on people's safety. This showed a willingness to learn and improve; however, further work was needed to ensure learning was consistently translated into sustained improvements in practice and outcomes for people.