Dalemain 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 remained 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 provider was in breach of legal regulation in relation to governance at the service.

This service scored 46 (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 always share their vision and strategy. There was a lack of opportunities for team cohesion and feedback. The absence of regular team meetings restricted collaboration and shared learning. There was a lack of supervision for the management team, as well as limited management meetings to demonstrate shared direction and communication. For example, in the absence of the home manager, the provider could not confirm what actions had been taken in response to previous concerns.

However, the manager had developed a culture which was positive and inclusive within the home.

Leaders understood the context in which the provider delivered care, treatment and support. The manager demonstrated they were passionate about their role; however, we identified gaps in their knowledge in relation to their regulatory requirements, such as when to notify CQC of incidents. The provider lacked oversight of both the service and the manager. The provider had not effectively monitored the performance of the manager, provided regular supervision, or ensured a registered manager was in place.

There had not been a registered manager for over 4 years. This concern had been highlighted at the previous assessment in 2022, indicating a sustained failure to comply with registration requirements.

However, feedback from staff and relatives about leaders was positive. Staff told us the manager and provider were visible around the home and approachable.

People did not always feel they could speak up and their voice would be heard. Whilst some staff members felt confident raising concerns, others gave examples where they had raised issues and no action was taken.

Opportunities for staff to speak up were limited. Only one staff team meeting had taken place in the past 12 months, and no staff surveys had been completed. We discussed this with the manager who told us there was an “Open door” policy. They acknowledged the feedback and planned to hold team meetings more regularly in future.

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 were recruited safely, and the provider supported some staff with flexible working arrangements and reasonable adjustments to accommodate personal circumstances and promote wellbeing. All staff had completed training in equality, diversity, and human rights.

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 oversight and auditing. No provider or manager walkarounds were recorded. Although the manager told us walkarounds took place, there was no evidence to support this, and concerns had not been identified.

Systems for auditing were inconsistent and not robust. Audits failed to identify significant issues, and where issues had been identified, it was unclear what action had been taken. For example, care plan audits had not been completed, so the provider had not identified issues with care plans and risk assessments. Care plans and risk assessments lacked detail and specific guidance for staff to follow. Some care plans were not in place for people’s specific needs or had not been updated to reflect changes This placed some people at risk of receiving inconsistent or unsafe care and treatment.

Internal audits of windows between May 2025 to June 2025 identified recurring concerns, yet no action had been taken, as we found the same concerns during our visit. Monthly medication audits failed to identify issues that would improve people’s safety.

The provider did not have systems in place to seek and act on feedback from staff, people, and family members. Complaints and concerns were not always investigated effectively. For example, a concern was raised approximately 6 months ago regarding medication administration. This concern was not documented or acted upon. The provider was aware of it but could not confirm what action the manager had taken in response.

At the previous assessment in 2022, we identified the provider had failed to ensure there were effective governance, records, and quality assurance measures in place, and they were in breach of legal regulations relating to good governance. The provider remained in breach of this regulation at this assessment.

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. However, there was limited evidence people had access to the community and local resources, or connections had been established with the local community.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. 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.

Some concerns raised at the last assessment in 2022 had not been addressed, which the home manager acknowledged. There was no home improvement plan or action plan in place for the provider to work towards. Following our on-site visit and feedback, the provider began developing an action plan which was shared with us.

Opportunities for learning were not consistently identified or shared with the team, as accidents and incidents were not analysed effectively. There were insufficient staff and management meetings to support continuous learning and reflection.

Additionally, there were missed opportunities to identify training needs, as competency checks and observations had not been completed or recorded after staff completed online training modules.

The provider was responsive to feedback provided following our assessment and had already taken some action.