Andover Nursing 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 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 outstanding. At this assessment, the rating has changed to requires improvement. This meant the management and leadership did not always create a culture which supported the delivery of high-quality, person-centred care. The provider was in breach of legal regulation in relation to governance at the service.

This service scored 62 (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.

People were supported in accordance with the provider’s values, and their individuality was respected. People were supported to attend local church services or representatives from people’s preferred churches came to the home when requested.

A staff member told us to prevent a closed culture open discussions took place. They told us, “Everyone’s interests’ matter, we do everything in people’s best interest and are comfortable to share any concerns we may have.” The registered manager was always transparent when reporting or following up on concerns. The management team worked to continuously improve the service, and this was evident in their response to our findings throughout this inspection.

The provider mostly had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge and experience to lead effectively. People and staff consistently told us about the positive and caring attitudes of the management team. Relatives feedback was mostly positive, 1 relative told us, “The manager is easy to speak to, and they do listen.”

Autistic people and people with a learning disability were supported to live a good, ordinary life as part of their community.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The registered manager told us they sought people’s views by listening to people, holding meetings with people and through day-to-day communication and surveys. We saw evidence survey results had been collated and used to drive improvement.

One person told us, “If I have a worry about my medication I talk to the Nurse in charge, and it gets resolved.” A relative told us, “I always get everything resolved if I have a worry.”

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. Staff told us they felt supported to give feedback and were treated equally, free from bullying or harassment. People with protected characteristics felt supported.

The provider held regular staff meetings and had recognition awards to engage with and celebrate the staff. The provider had good staff retention records with a lot of staff staying in post for many years. The registered manager told us they supported 1 person from a particular faith, they said, “We have carers who have the same faith, they can speak this person’s language and invite them to pray with them.”

The provider did not have effective governance systems which drove improvement and did not always act on the best information about risk, performance and outcomes. For example, the provider had not identified, through their auditing processes, the concerns we found on inspection in relation to medicines management, recruitment, care records and mental capacity assessments. Therefore, shortfalls had not been picked up and addressed prior to our inspection. However, the provider was responsive throughout our inspection and immediately started to make improvements.

The provider had policies and procedures in place. We found the provider’s Positive Behaviour Support Policy and the provider’s Medicines Policy both referred to a different care home. This had not been picked up by the provider when they were reviewed in April 2025. We spoke to the provider about this; they told us they would update the policies.

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 registered manager and their staff told us about their extensive community engagement which included, dementia training in the community including at local schools and creating a dementia coffee shop which was open to the public. The registered manager sought advice and support from professionals when required. The service shared best practice with other care homes which supported learning and improvement. People of all abilities were supported in a culture that was built to focus on enabling people to enjoy their lives.

The provider had a strong focus on continuous learning and innovation and across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

The registered manager gave us examples of innovation. They told us how they had collaborated with a well-known company to develop a razor specifically designed to be used by a staff member shaving a person. They participated in the research, development and the trials of this razor which is now in production and used in the home. The provider received positive feedback from people and their families and staff felt more confident to support people with shaving.

The service worked creatively to enhance people’s quality of life. One person wanted to attend an activity in London, the provider arranged for a local nursing home to accommodate the person for a night so they could attend their chosen activity while retaining their required care and support. Another person wanted to be involved in the garden, they were supported to make adaptations to their wheelchair so they could carry enough water to independently water the garden.

The deputy manager told us about their involvement in a local college’s long-term project to look at, trial and develop new ways of offering a modified diet. They said, “We want to be part of the journey to improve textured modified dining even further.”

People were supported to undertake the same training as staff where they expressed an interest.

This model of care aligned to current best practice guidance right support, right care, right culture. We reviewed evidence in team meetings and quality assurance surveys which assured us leaders were collaborating with people, their representatives and staff, to build a culture focused on enabling people to enjoy a full life.