Worsley Lodge

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 at 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 the legal regulations relating to governance.

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 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 service held regular team meetings and conducted handovers between shifts, which supported staff to share information and work collaboratively. However, there was limited evidence of effective provider oversight and support.

The registered manager hadidentifieda need for increased staffing levels during evening periods and had implemented a twilight shift to address this. Staff told us this had a positive impact, enabling them to deliver more person-centred care rather than task-focused care. Despite this, the twilight shift was removed by the provider at the beginning of 2026, staff told us that this had a negative impact on the service.At the time of the inspection, the provider told usthe shift was removedas it was no longer deemed necessaryas dependencies of residents had changedand if thestaffingdependency toolindicated the need for more staffing, then this would be implementedimmediately on themanager’srequest.The registered manageradvisedthat he was going to complete a dependency review during this inspection

Not all leaders understood the context in which the provider delivered care,treatment,and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge,experience,and credibility to lead effectively, or they did not always do so with integrity,openness,and honesty.

The registered managerdemonstratedtheappropriate knowledge,experience,and skills to lead the service. However, oversightof the systemrequired strengthening. Feedbackregardingthe visibility and accessibility of the registered manager was inconsistent. Some people and their relatives told us they were unaware of who the registered manager was and would approach senior care staff instead. Others reported that they had been able to approach the registered manager directly and that concerns raised had been appropriately addressed and resolved.

The service had not fully ensured that leadership was consistently visible and proactive in engaging with people,relatives,and staff to drive learning and improvement.

Staff reported feeling supported by the management team and described them as approachable. One staff member commented, “They are aware of issues within the service; while there are a few ongoing concerns, the majority are addressed promptly.”

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

Staff were not familiar with the term “Freedom to speak up” which the provider told us is not a term usedby them.Information about how to raise concerns was seen to be available within the service. Staff confirmed they understood whistleblowing processes and were aware of external organisations, such as the local authority and the Care Quality Commission (CQC), where concerns could be escalated.

Feedback received from external stakeholdersindicatedthat staff reported not feeling able to speak upwhen asked about it, however when asked during this inspectionsome staff told us that they felt able to approach the registered manager to raise concerns.

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.

Policies were current and readily accessible to staff, including an equality, diversity and inclusion policy that complied with relevant legal requirements. Staff spoke positively about the home’s inclusive culture, reporting that they felt supported by management and treated fairly. They described the manager as approachable, flexible and responsive to individual needs. For example, flexible working arrangements had been implemented to help retain staff members who might otherwise have left the service, and prompt support was provided to enable a staff member to transition into a different role within the organisation.

Theprovider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk,performance,and outcomes, or share this securely with others whenappropriate.

Quality assurance processes wereestablishedwithin the service; however, this assessmentidentifiedseveral significant gaps in their effectiveness. Care plans were not consistentlyaccurateor reflective of individuals’ current needs. Furthermore, existing monitoring and auditing systems had failed to detect critical shortfalls, including instances where care plans were not adhered to, particularly in relation to regular turning and repositioning.

Environmental monitoring was also found to be lacking. Issues such as stained furniture and odours in communal lounges and individuals’ rooms had not beenidentifiedor addressed,indicatinga lack of robust oversight.

In addition, it was unclear whether auditing processes had sufficiently assessed staffing levels. Evidence suggested that staffing was not adequate to meet the complexity of people’s needs, raising concerns about the effectiveness of workforce planning and oversight mechanisms.

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.

People were supported to remain active and engaged members of their community through a wide range of regular outings, events, and meaningful activities. A comprehensive and varied activity programme was in place, offering enjoyable opportunities for both individuals and their families.

Families were warmly welcomed and actively encouraged to participate in daily life, helping to maintain strong relationships and ensure continuity of care. The service also facilitated access to advocacy where required, ensuring that individuals’ views, wishes, and voices were heard and respected.

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.

The provider had audit and governance systems in place, however we did not see evidence of audits completed in some key areas that were needed, to fully understand the issues affecting people in the service. Insights from incidents and audits were not always analysed to identify opportunities for learning and drive improvements in practice. However, we saw evidence that lessons learnt from individual issues were shared with staff.