Abington Park View Care 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 means we looked for evidence that leadership, management and governance assured high-quality, person-centred care and promoted an open, fair culture.
At our last assessment, this key question was rated good. At this assessment, it has changed to requires improvement. This meant governance arrangements did not always ensure effective oversight and accountability.
Audits and quality checks had not consistently identified risks or ensured timely actions. Recruitment oversight and record monitoring required improvement. The provider was in breach of the legal regulation in relation to good 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 had a clear vision and strategy, supported by relevant policies and procedures. Staff understood their roles and knew what was expected of them in terms of delivering care. However, the day-to-day management and implementation of these values required further embedding across the service.

We observed that while the overall vision was communicated, it was not consistently reflected in day-to-day practice, particularly in how the service responded to the individual needs of each person. While there was a focus on creating an inclusive environment, day-to-day management lacked clarity and consistency. The registered manager acknowledged that further work was needed to strengthen the shared culture across the team and improve management oversight. Immediate action was being taken to ensure that the values of the provider were more consistently applied in daily operations.

The provider did not always have leaders who understood the context in which care was delivered, and they did not always embody the culture and values of their workforce and organisation. Leadership lacked consistency and clarity, which impacted the delivery of high-quality care.
The service had a clear leadership structure, and the registered manager was approachable, supportive, and well-regarded by staff. Staff morale was positive, with many reporting that they felt valued and listened to. One staff member commented, “The manager is very supportive, and we feel confident raising any concerns.” Relatives also spoke positively about communication and the manager's approachability.

However, while day-to-day culture and management visibility were strong, governance systems and oversight processes were not fully effective. Internal audits and monitoring had not identified key shortfalls in recruitment documentation, risk assessments, and Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) records. This lack of oversight meant there was limited assurance that quality and compliance were consistently maintained across the service.

The registered manager acknowledged these issues and took immediate action to strengthen governance processes. They committed to improving internal audits and ensuring that all recruitment checks, care documentation, and capacity assessments were thoroughly reviewed. Management meetings and regular audits have been introduced to better monitor performance and identify areas for improvement.

Despite the weaknesses in governance, we found leadership to be transparent and responsive. The registered manager demonstrated accountability and a clear commitment to making sustainable improvements, with a focus on ensuring safer, high-quality, person-centred care.

The provider fostered a positive culture where people felt they could speak up, and their voices were heard.

A range of mechanisms were in place to encourage people, relatives, and staff to raise concerns or provide feedback. Staff had regular supervisions, team meetings, and access to a whistleblowing policy. People, relatives, and staff told us they felt confident in raising concerns with the leadership team. One staff member shared, “I feel comfortable raising any concerns. Management is approachable and acts.”

Staff were supported by their colleagues, and most reported feeling heard. People and relatives also said they felt comfortable expressing concerns, and that staff responded promptly to any issues raised.

The registered manager was transparent in addressing concerns and worked proactively to ensure open communication throughout the service. Staff were encouraged to speak up without fear of reprisal, and systems were in place to ensure their voices were listened to and acted upon. The manager’s openness and willingness to take feedback positively contributed to a culture where staff and people felt valued and supported.

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 promoted an inclusive workplace and ensured equality of opportunity for all staff. Staff were treated fairly and respectfully, including in relation to their protected characteristics such as flexible working arrangements and time to observe their faith.

The workforce was diverse, with staff bringing a range of skills and experience that enriched the quality of care provided. Staff told us they were positive about their roles and felt supported and treated equally. They also had equal access to training and development opportunities and were encouraged to progress in their careers.

Staff said they felt comfortable raising concerns and confident that they would be listened to. Regular staff meetings provided opportunities to share ideas and feedback. The provider also held meetings with people and relatives to ensure everyone’s voice was heard. Leaders encouraged openness and inclusion, creating a positive and respectful culture focused on delivering good-quality care.

The provider 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 when appropriate.

The provider’s oversight, governance, and monitoring systems were not always effective in identifying and addressing shortfalls. Some issues found during this assessment had not been identified through internal audits or routine management checks. There was a lack of robust oversight in relation to people’s care documentation, risk monitoring, and use of agency staff.

For example, profiles for agency staff kept in the office showed outdated training dates, and there was no evidence of completed agency induction forms. This meant there was limited assurance that agency staff were fully aware of people’s individual needs and service procedures. Audits were taking place but did not always detect these shortfalls, indicating that the auditing process required strengthening.

CCTV was installed in communal areas and corridors. The registered manager said families had been informed of its use; however, there was no evidence of signed consent forms or Mental Capacity Act and Best Interest decisions to support this. The manager confirmed that the system was not live-monitored and was only reviewed retrospectively when concerns were raised.

Despite these weaknesses, leaders acted promptly once concerns were identified. The registered manager began reviewing agency records, strengthened the audit schedule, and implemented clearer checks to ensure governance and accountability systems were effective in practice.

The provider understood their duty to collaborate and work in partnership so that services worked seamlessly for people. They shared information and learning with partners and worked collaboratively for improvement.
The provider and management team maintained positive working relationships with external professionals, including GPs, social workers, and other healthcare partners. Staff worked closely with these professionals to ensure people’s changing health and care needs were met promptly and effectively.

Relatives told us they were kept informed about changes in care and that communication between the service and external agencies was good. Professionals we spoke with said staff sought advice when needed and followed recommendations to support people’s wellbeing.

The provider also encouraged community involvement. Events, activities, and visits were arranged to help people stay connected and engaged with the wider community. Staff supported people to attend appointments and outings safely, helping them maintain independence and social contact.

This collaborative approach helped ensure continuity of care, supported improvement, and promoted a positive experience for people using the service.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. Opportunities to deliver equality of experience, outcomes and quality of life for people were not fully embedded to actively contribute to safe, effective practice and learning.
The provider was committed to learning and improving the quality of care. However, the lack of effective oversight and leadership meant that some opportunities for improvement were missed. For example, a relative had raised concerns about unsecured wardrobes prior to the assessment, but the issue had not been addressed. It was only rectified after this was highlighted during the assessment.

Routine management walkarounds had also failed to identify several environmental concerns, such as a sharps bin stored in a bedroom and a medication trolley left unsecured in the dining room. Once these issues were pointed out, they were addressed immediately.

The registered manager acknowledged these gaps and accepted that oversight and learning processes needed to be strengthened. Lessons learned from incidents, audits, and feedback were being shared with staff, but these needed further embedding to ensure consistent practice and sustained improvement.

Leaders and staff were responsive to feedback and acted quickly to address concerns raised during the assessment. The provider’s willingness to accept feedback positively and take immediate corrective action demonstrated a commitment to continuous improvement, although systems needed to be more proactive rather than reactive.