Temple Ewell 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 assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in 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 governance at 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 provider did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. The culture within the service was not open and transparent. The management team had not been open with other agencies when incidents happened. They had not informed outside agencies so they could investigate concerns. Some relatives told us they did not know who the registered manager was and had not spoken to them, though they visited the service each day. Staff meetings had highlighted people’s relatives were not always told about changes in people’s health and when the GPhad been called. A relative told us, they would ask for the GP to be called for their family member but had not been updated about the outcome.

The registered manager had not promoted a culture of learning. Staff meetings did not cover the culture and vision for the service and how staff could support and collaborate to make improvement.

The provider’s website states, ‘The Home aims to provide high quality personalised nursing care to meet the needs of the individual whilst encouraging choice and independence in a friendly, relaxed and homely environment.’ There was little evidence there was a clear strategy to ensure the vision was met as there were significant shortfalls in the quality of the care people were receiving.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty. The management team had not demonstrated they had the skills and knowledge to deliver high quality treatment and support.

The director of care services had completed monthly visits and walk arounds the service. However, the report of the visit showed they had not spent time talking with staff and did not attend staff meetings, to support staff to raise any concerns they had. Staff told us, they had a support system within the care team but did not always feel supported by the management team. Staff told us they had some supervision, but this was not frequent.

The management team had not completed spot checks to make sure staff were delivering care and support to a high standard.

People did not always feel they could speak up and that their voice would be heard. Many of the staff were sponsored by the provider, they told us, they did not always feel comfortable to raise concerns as it might be used against them. Staff attended meetings and were asked if they wanted to raise any concerns. When subjects had been raised, staff were told these would be investigated. However, there were no action plans put in place following the meetings and there was no update at the next meeting. Staff told us they were not confident the changes would be made.

People and relatives told us they knew how to complain and were confident to raise general concerns with staff.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. People were supported by staff from different countries and cultures. However, staff told us, there had been no support to understand each other’s cultures or introduce people to their culture. Staff told us their work pattern was flexible to meet their care or spiritual needs.

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.The provider had poor oversight of the service and the systems in place within the service to monitor the quality of care had not been effective in identifying shortfalls and making improvements when needed.

The clinical lead completed regular audits including care plans, wounds and medicines. However, they were part of the team who wrote the care plans, completed wound documentation and medicines, this meant they were checking their own work. The registered manager told us as they did not have a clinical background, they had relied on the clinical lead to ensure good practice and were unaware there were shortfalls such as poor wound management. There were no systems in place for senior management, who had a clinical background to check the audits were effective and ensure clinical outcomes were met. The governance systems in place were not effective and failed to identify the issues we found during the inspection.

The provider had commissioned a ‘mock inspection’ by an external consultant in March 2026, which had identified shortfalls within the service. The registered manager had put an action plan in place to rectify the shortfalls; at the time of the inspection the registered manager had signed some areas as complete. However, these shortfalls remained at this inspection. The provider had not overseen the action plan to ensure improvements were made in a timely way

The management team were not aware of their responsibility to notify CQC of certain events that happen within the service. We had not received any notifications for wounds and unexplained bruising. Following our onsite visit, we received backdated notifications for wounds, which met the criteria for notification.

The provider did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.Staff had not made sure people who had autism needs and a learning disability were referred to specialist nursing support and had strategies in place to promote access to community support if they wanted it.

People had not always been referred to specialists when this had not been identified by staff. When staff had identified people’s needs they had been referred to healthcare professionals.

The provider did not focus on continuous learning, innovation and improvement across the organisation. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The quality of the service had deteriorated significantly since our last inspection. There was not a culture of learning, systems in place did not identify and support learning opportunities. Incidents had not been used as a learning opportunity to reduce the risk of them happening again. People’s care and support had not been reviewed to ensure staff were providing safe care and a good quality of life. The management team had not investigated incidents in an open and transparent way to identify underlying causes to drive improvement across the service.