Arncliffe Court 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 – this means we looked for evidence 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 inadequate. At this assessment the rating has remained inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider was in breach of legal regulation in relation to the governance of the service.

This service scored 29 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

For example, leaders failed to ensure people consistently received high-quality, safe care. When we asked a provider and the newly appointed manager about their understanding of the implications of the service being placed under special measures, their responses indicated a lack of awareness. The new manager stated, “I haven’t had a chance to look at the issues. I wasn’t informed the service was under special measures” and “It just means we need help.” These responses demonstrated a lack of shared understanding, clear direction, and a cohesive, proactive culture among leaders and staff.

The findings from this assessment indicated the culture of the service remains insufficiently focused on delivering person-centred care and ensuring people’s safety and wellbeing. Although the provider had an action plan in place, there was limited evidence of progress against the identified actions or of staff engagement in its implementation.

We identified several ongoing concerns which had been highlighted in our previous assessment, including issues related to quality assurance systems, management oversight, risk management, and medicines management. This demonstrated a continued failure by the provider to effectively act on known issues impacting the safety, quality, and leadership of the service.

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

At the time of our assessment, the new management team had introduced additional processes and procedures with the support of the consultancy team, for example, new procedure for reviewing accidents and incidents, and consent to care records. However, these had not been in place long enough to demonstrate whether they were effective or sustainable.

People did not always feel they could speak up and their voice would be heard.

For example, staff reported although they felt able to raise concerns, they did not have confidence these were consistently listened to or acted upon. Staff described experiences of bullying and feeling undermined by a previous manager, as well as concerns about how people were supported, which they felt were not appropriately considered or addressed.

Additionally, one staff member told us they had repeatedly attempted to contact the manager to address a concern but had not received a response. Staff also told us, information was not always kept confidential, which could make staff less likely to speak openly. However, the provider had systems in place, including a whistleblowing policy, intended to support staff in raising concerns and speaking out.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

For example, not all staff felt heard or supported in their roles. Feedback from some staff highlighted a disconnect between leadership and the wider staff team, with individuals reporting they did not feel fully listened to or valued.

Although the provider employed a diverse workforce from a range of backgrounds and had systems and processes in place to support flexible working and the implementation of reasonable adjustments, these were not always experienced positively by staff in practice. However, some staff told us they enjoyed working at Arncliffe Court Care Home. One staff member told us, “We are like a family here, we support each other. Times have been hard, but we pull through as a team.”

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.

At our previous assessment, we identified concerns regarding the safety and governance of the service, and enforcement action was taken. During this assessment, we continued to find significant issues relating to ineffective management and oversight.

For example, the lack of consistency within the management team meant systems and processes were not applied reliably. As a result, previously identified issues had not been addressed, and there was insufficient oversight of care delivery, impacting the quality and safety of the service. This was due to a lack of effective provider and management oversight, particularly considering frequent changes in management.

Quality assurance systems and processes were not effectively implemented to support safety and continuous improvement. There was a lack of robust oversight at both provider and manager levels. Although audits had been completed, these were not effective in identifying or addressing the concerns found during our assessment. Issues relating to the environment, medicines management, record keeping, and consent to care had not been adequately identified or acted upon.

People and their relatives commented on the inconsistency within the management team, reinforcing concerns about the stability and effectiveness of leadership.

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.

For example, a lack of effective oversight and robust monitoring within the service impacted the providers ability to work collaboratively and share information appropriately. We identified a person who had no funds available in their account. The provider had not escalated this issue to the local authority or taken appropriate steps to liaise with relevant external agencies to resolve the matter. As a result, the person was left without access to essential items and activities, such as personal care services or opportunities to visit relatives which negatively impacted their wellbeing and quality of life.

There was minimal evidence to show people had meaningful access to the wider community. Opportunities for people to engage with external groups or participate in community activities were minimal. However, since our last assessment, the provider has been working with the local authority team to address the concerns raised. Feedback from the local authority indicates that some improvements have been made; however, progress has been limited due to inconsistencies in management.

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, outcomes and quality of life for people. They did not actively contribute to safe, effective practice and research.

Since the last assessment, managers and leaders had not implemented safe or effective systems to drive improvement within the service. There had been a lack of robust oversight and learning from identified issues, which resulted in ongoing concerns remaining unaddressed. For example, concerns raised during our last assessment in August 2025 had not been addressed, including issues relating to consent to care records, medicines management, and risks to people. Risks were not effectively managed, which limited the provider’s ability to improve outcomes for people.

The quality of the care had not improved sufficiently to ensure people received care which was safe, person centred or responsive to their needs and preferences. For example, staff told us they had their competency assessed, and we saw records to support this. However, with the concerns found, we were not assured the assessments were effective in assessing staff competence. The provider completed audits regularly and identified some areas for improvement. However, the audits had not identified all the concerns we identified at this assessment.

The provider had engaged a consultancy agency to support improvements. At the time of our assessment, this had not yet resulted in sustained or measurable improvements in the quality and safety of the service.