Abbey Rose

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.

This service scored 57 (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.

The home had experienced a period of unsettled leadership which had a negative impact on the vision and strategy of Abbey Rose. We received the following comments from staff regarding the management of Abbey Rose. “Since April 2025 three managers were appointed and subsequently left. At present the registered manager spends their time at the other home they are registered for." And “[name of care manager] is running the home but they aren’t experienced in this, its not fair to have all the responsibility.” This meant the provider had not established a clear or consistent strategy, and there was limited evidence of how their vision was put into practice. Despite this, the staff team were committed to supporting each other and promoting person centred care. The care manager lead by example which created a positive environment and an open and inclusive culture. Most staff spoke positively about their roles and told us they felt supported in their work. Staff described the culture of Abbey Rose as being “Caring, respectful and supportive”.

We asked the provider for assurances regarding how they would improve the stability of management at Abbey Rose. They explained that policies and procedures underpinned working practices, and this was supported by training and monitoring of staff working practices in spot checks and supervisions.

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. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The registered manager was registered with the CQC 30 April 2026 and told us they had only been able to visit Abbey Rose “Twice, due to demands on working at another service” where they are also registered. Relatives told us they had not met the registered manager, they said "We've never met the higher up manager." And “I haven't and I don't think mum has.”

A computer system had been implemented in 2025; however not all information had been transferred from paper records. The care manager told us this was meaning ‘double’ the work for them as they “haven’t got the time to transfer everything” effectively. This caused confusion having duplicate records and not being able to use the system to its full potential. The Local Authority raised this in March 2026 to “ensure electronic systems were embedded”.

A care manager was responsible for all aspects of managing the service with telephone advice from the registered manager. A relative said “It's [Name of senior care co-ordinator] who runs the place on a day-to-day basis.”

The care manager understood the responsibilities under the duty of candour and notification to refer to the CQC and other agencies including the local authority when appropriate.

We asked the provider for assurances regarding how they would improve the management and governance at Abbey Rose. However, we haven’t been able to assess the effectiveness and sustainability of these plans.

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

Staff knew how to raise concerns, including how to ‘whistleblow’ if needed and how to access support. Whistleblowing is the act of reporting wrongdoing, misconduct, or illegal activities within an organisation. Staff told us they were confident and ‘comfortable’ to raise any concerns or complaints, that would be dealt with promptly and professionally. Staff told us, “I am familiar with the speaking-up policies and would be confident in using them if I needed to.”

Relatives told us they would have no hesitation in raising a concern if needed. They said they would tell a member of staff or ring the office to speak to a member of the team. Everyone we spoke with was confident they would be listened to, and their concern would be satisfactorily resolved.

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 care manager encouraged an open-door policy, allowing staff to raise concerns or suggestions comfortably. Staff told us they felt valued and respected by both the provider and the care manager; however, they didn’t know the registered manager yet. Staff told us they were able to provide feedback and were treated equally, free from bullying or harassment.

The provider had a policy in place to ensure staff were treated fairly and had equal opportunities to learn and develop their roles within the organisation. There were fair recruitment processes in place, which helped to protect the rights of staff under the Equality Act. We observed staff working together and communicating effectively and respectfully with each other during our visits.

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 registered manager was registered for another service owned by the provider, which they had to prioritise oversight. There was no effective provider-level oversight within the home. Audits of the management of medicines or environment had not identified the areas we had identified. This meant the monitoring systems were not robust.

We asked the provider for their assurances that Abbey Rose would have sufficient registered manager and provider oversight to ensure regulatory compliance. However, we haven’t been able to assess the effectiveness and sustainability of these plans.

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

Social care professionals told us, improvements were often driven by external involvement rather than proactive internal leadership. The service had limited links with the local community. Relatives told us “I’ve not seen any activities outside of the home in the local community.” We saw any activities were based in the home unless relatives or friends wanted to take their relatives out.

The registered manager and care manager told us they had not had the opportunity to attend any local provider support groups. This meant they were not able to network, share experiences and ideas of ways to develop Abbey Rose.

The care manager worked in partnership with a range of health and social care professionals and the local authority. Records showed these included people seeing GPs and community nurses.

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 environment was not conducive to supporting people with Dementia to navigate the home and promote their independence. There was limited signage throughout the home to enable people to navigate the home without the need for staff guidance and prompt. The home had standard identical doors, which can cause confusion. The home did not have any visual cues to help people recognise their own private space. The provider had not considered Strong colour contrast between walls, floors, and furniture can help people to distinguish between items easier.

Despite the environment showing signs of deterioration and not being designed to support people living with dementia, there was no evidence of an improvement plan or provider-led action to address these issues.

Any lessons learned were shared wider within the staff group. Staff told us, “Accidents and incidents are shared with us and discussed so improvements can be made.”