Marian 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. 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 good governance at the service.

This service scored 54 (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.

Improvements were required in the governance of the service to ensure it was robust and effective in day-to-day quality assurance. Audit processes needed strengthening to help the management team identify problems and the actions required. We looked at a range of the provider’s audits, and these did not always reflect our findings during this inspection.

Staff described a positive and supportive culture within the home. One staff member told us they felt the culture was “good” and that everyone worked well together. The registered manager also described a strong team ethos, saying the service was, “like a big extended family”, with many long-standing staff who worked well as a team and supported each other.

The provider had a statement of purpose. This document did not set out clear information about the services provided, or the needs of the people the service is designed to support. As a result, it did not provide a clear framework for staff, people using the service or external stakeholders to understand the provider’s values, expectations or safeguards.

We raised the concerns we had found during our inspection with the registered manager and the provider. They were responsive and took action to address some of the issues immediately and added to their action plan the other improvements required.

People experienced a warm and caring atmosphere in the home. Staff interactions were positive and respectful.

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.

We received consistently positive feedback from people, staff and relatives regarding the registered manager and the staff team. The registered manager was visible within the service and involved in the day‑to‑day running of the home. However, whilst the registered manager was compassionate and caring, they did not always have effective oversight of care delivery, treatment and support. This meant they were not consistently identifying or addressing shortfalls in people’s care and learning from incidents. The registered manager was committed to delivering a good service. However, gaps in governance and risk oversight meant people could not always be assured the service was consistently well-led and lessons were used to drive improvements in care quality.

Staff told us managers were visible, approachable and led by example. One staff member explained that the registered manager would step in to support day‑to‑day tasks when needed, such as helping to monitor communal areas. Another staff member told us there was good teamwork, explaining that “everyone works together.”

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

Staff told us they could speak up and that their voice would be heard. Staff said they had access to information about whistleblowing and speaking up and felt able to raise concerns with the management team if required.

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.

The provider had relevant policies and procedures in place to promote equity in their recruitment and development opportunities, and to review staff needs. Staff told us they had access to training and development opportunities and were able to request any additional support required. Staff felt they was treated fairly.

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 registered manager did not always have effective oversight of the audits in place. Although quality assurance systems and processes existed, they required improvement. For example, they had not identified the shortfalls and key risks we found during this inspection in relation to the environment, fire safety, risk management, care planning, staff recruitment, staff competency and oversight of people’s finances. In addition, they had not ensured people’s rights, choices and outcomes were being consistently promoted in line with Right support, right care, right culture principles. Quality audits were not sufficiently detailed and did not provide assurance risks were being well managed and improvements were embedded.

The provider had an improvement plan in place following a visit from the local authority in October 2025, with various actions identified for ongoing improvement. Some of these had been completed, others remained in progress and our visit had highlighted several additional concerns not captured on the improvement plan.

The registered manager assured us that, following our feedback, they would be reviewing and strengthening their audit processes to ensure they were more robust, and able to identify issues promptly.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

There had been a delay with escalating a referral to the relevant healthcare professionals regarding a person’s mobility needs and barriers to accessing the local community. Although the registered manager had now followed this up, there had been a significant delay in taking action so improvements could be made for the person. We did receive positive feedback about the service from healthcare professionals who had worked directly with the service. The registered manager had worked with the local authority to address areas of improvement they had identified and this work was still in progress.

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 been collaborating with commissioning bodies to raise the standard of care and strengthen the quality of documentation. Despite this, additional work was still needed to evidence sustained improvement.

The lack of effective systems and processes meant concerns were not consistently identified or addressed, limiting opportunities for learning and improvement. As a result, there was limited evidence of lessons being shared with staff to support improved practice.

The registered manager told us the service was exploring new ways of working to support continuous improvement. They said they were looking into moving to a different electronic care management system. This was intended to enhance oversight and support more efficient, accurate record‑keeping. They also had some plans in place to improve the environment and make it more homely and comfortable for people.

During our assessment the registered manager started to take action to address the issues identified during our inspection. However, they were not part of any external learning forums or networks related to supporting people with a learning disability and autistic people that could support ongoing improvement. As a result, we did not always see evidence of opportunities to learn from others or embed best practice.