Peregrine 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 Good.

At this assessment, the rating has changed to Requires Improvement.

The service was in breach of the legal regulation in relation to governance as the provider’s quality assurance arrangements were not effective.

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. Staff were able to demonstrate an understanding of the provider’s ethos and values.

The provider and registered manager did not always have the skills, knowledge and experience to lead effectively.

Whilst there was an established registered manager at the service to support and guide staff, the provider’s and registered manager’s governance arrangements had failed to identify the issues we found during our assessment. This lack of oversight potentially placed people at risk of receiving unsuitable or unsafe care.

Not all relatives spoken with knew who the registered manager was, with some referring to the Team Leader as the registered manager. Comments included, “I don’t know who the manager is. I talk to [Name of Team Leader] and they are approachable” and “Now I am not even sure who is in charge.” However, other relatives spoke positively about the registered manager. Comments included, “The manager [Name] is very friendly, polite and caring”, “[Name of registered manager] is very sweet and is always available in the week and approachable” and “[Name] is the registered manager, and they are very pleasant and generally has been helpful.”

The registered manager told us they felt valued and supported by the organisation.The registered manager confirmed they received regular formal supervision from the regional manager and had a good rapport and relationship with them. Staffs’ comments about the registered manager were positive and included, “[Name] of registered manager is wonderful, very supportive” and “I feel Peregrine House is well managed and [Name of registered manager] is great.”

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

Staff told us they felt confident to raise an issue or concern. Comments included, “I would speak up if I had any concerns. I am not afraid to speak my mind, should the need arise” and “Of course, if I was unhappy, I would speak to the manager or regional manager.” Staff had access to twenty-four hours a day, seven days a week, counselling and advice service. An annual staff survey was conducted to enable employees to share their experience of working at Peregrine House. Staff participated in regular team meetings, where staff could raise concerns or make suggestions.

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.

There was a diverse workforce at the service, with staff employed from a wide range of backgrounds, cultures, and experiences.Staff told us they were treated fairly, felt supported and valued. Staff spoken with confirmed there were opportunities to discuss their development through formal supervision and appraisal. Staff felt there was good teamwork at the service. The provider understood the importance of having a fair and inclusive workplace for all staff to work in. Staff received relevant training to inform their knowledge and understanding of equality, inclusivity and fairness in the workplace.

The provider did not have effective systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes.

The quality assurance and governance arrangements in place were not effective in identifying shortfalls found at the service as part of this assessment. As stated within this assessment report, this referred to risks to people’s safety were not routinely safe, identified and recorded. Care plans were not routinely accurate or recorded all of a person’s care and support needs. Not all care provided by staff for people using the service was responsive and person-centred.

Senior staff were not available to provide support and guidance to staff to enable them to effectively carry out their roles and responsibilities. Staff did not always recognise their responsibility and accountability to identify and question poor practice with colleagues when this was evident. For example, when witnessing poor moving and handling practices or when care and support provided for people using the service was not responsive and person-centred.

Relatives were generally positive about the overall management of the service. This was from relatives directly spoken with and from information recorded on an external website for reviewing care homes since 1 January 2025. Comments included, “We have always found the home excellent in all respects, always helpful, always cheerful, we know all here are in good hands” and “Peregrine House is a very welcoming care home. I recommend it.” However, a concern was raised with us whereby a relative had received an invoice meant for another person using the service, representing a personal data breach under data protection law.

Services that provide health and social care to people are required to inform the Care Quality Commission, (CQC), of important events that happen in the service. This enables us to check that appropriate action had been taken. The provider and registered manager understood their responsibilities to submit statutory notifications to the Care Quality Commission as required.

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.

The provider did not always focus on continuous learning and improvement across the organisation and local system. They did not always actively contribute to safe and effective practice.

The provider’s audits had not been effective at identifying where improvements were required. Concerns we identified during our assessment had not been picked up by the provider’s internal audits. Improvements were required to ensure lessons were learned to continually identify and embed good practice, and to identify shortfalls at the earliest opportunity.