Deneside Court

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 provider had in place a range of processes to maintain the effective running of the service. Staff had mixed views on the management of the service. Some felt management were approachable, whilst others reflected managers were not always proactive in dealing with matters. Relatives and professionals were positive about the manager and the improvements they had made, since taking up post. However, the manager had been in post since May 2024 and had still not commenced the formal registration process. People and staff felt the manager was approachable. Some checks and audits were undertaken, although issues identified were not always consistently followed up. Professionals told us that communication with the service was good and all staff responded to concerns and guidance.

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.

The provider had a clear vision of the culture and outcomes required for the home. People and professionals were optimistic about the manager and their positive impact on the service. Staff shared this vision and understanding of the need to provide high quality, personal and safe care. A staff member commented, “We get support from [manager]. They are a really good manager, and [name] the deputy. [Name] the regional manager comes in quite regularly too. If you want support, you just go downstairs; you can speak to anyone.” Another staff member told us, “I love it here. I love all the residents. It’s about making a difference. They become family to you. The best thing is having a relationship with them. You get to know what they are thinking.”

People, relatives and professionals told us all the staff at the home were kind, approachable, patient and understanding. A professional told us about how staff had supported one person. They said, “I was very impressed with the attitude and approach taken by the manager and team – in other circumstances the placement may well have broken down, yet the person’s behaviour had largely settled within a week. Despite the testing circumstances I observed staff display a consistent, positive regard towards the person, which I think was instrumental in building their trust and deescalating their behaviour.”

The provider 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, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

People and relatives were positive about the manager and felt they had been a constructive influence on the service since they had come to the home. Staff and professionals also highlighted the progress made by the service and the proactive attitude of the manager. A staff member told us, “I love the support of my manager and seniors, they do well to listen to my needs, when needed, especially adjusting my rota to suit childcare.” Another staff member felt the service was improving and developing under the current leadership. They said, “I am positive about the future – I love the people that I care for.”

A professional said, “The manager, who is currently in post, has developed an improved leadership within the home, something that was lacking and impacted the home previously, prior to [manager] coming into post. They have the right level of attention to detail, knowledge about the residents and also the staff within the building” Another professional told us, “[Manager] has been prompt in reviewing and resolving any concerns. I have been impressed by the proactive management, who work collaboratively with a number of professionals”

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

People and relatives said they could easily raise any issues or concerns. Two relatives told us that sometimes matters weren’t always addressed immediately. A relative told us, “When we do speak with staff, on the whole they listen, but sometimes we have to keep saying it.” Other relatives felt action was taken if they had concerns. Comments included, “Not (made) a formal complaint – but the matter was dealt with accordingly and we feel we can raise concerns or issues” and “I haven’t really (made a complaint) but I am sure it would be dealt with accordingly and timely.”

Staff had received a range of training including safeguarding adults training and how to raise whistle blowing concerns. Training staff spoke at length how they covered whistle blowing in detail during induction, and how there were various avenues for staff to raise concerns.

Staff felt positive about the culture of the home and said they could raise issues, if they were concerned. A staff member said, “I would go to [manager] – I have a good relationship with them. If I had any concerns, I would go to head office – they would take things seriously.”

The provider strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who worked for them.

The culture of the of the service strongly valued diversity and people from a range of cultures worked within the service. The home had a number of staff from abroad who were working under the government sponsorship system. They told us they were fairly treated and well accepted within the home. Comments from people included, “I have experienced no racism. I am fairly supported and in a proper manner” and “One of the outstanding things about the home is it's equality culture; everyone is being treated fairly and equal.”

Staff not on sponsored contracts were positive about workers who were being sponsored. They felt they had worked hard to understand a different culture and had some exceptional skills, particularly around supporting people with behavioural issues. A staff member commented, “They had to deal with the culture as well as getting to know the role. We’ve had some really good, sponsored staff. Staff who work really well with behaviour.”

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 service had a manager in post who had been working at the service since May 2024. They had initially applied to register but had been unable to do so for technical reasons. The application system changed in November 2024 to assist the process. However, there was no evidence that a formal application had been submitted, and the manager was unable to supply evidence that they had formally commenced the registration process.

When the previous registered manager deregistered in October 2024, the provider had not formally notified CQC of the absence of a registered manager, as legally required. This was a breach of the legal registration regulation relating to notifying CQC of changes. We will deal with this matter outside the assessment process and will subsequently report on any action we take in relation to this matter.

The provider had in place a range of audits for areas such as infection control, care records, staff supervisions, medicines, fire safety and health and safety. These reports contained actions that were required to be completed. However, we noted that a number of actions remained at the ‘in-progress’ stage and some issues continued to be noted in subsequent audits. For example, a care plan review undertaken in January 2025 was rated as ‘requires improvement’ and listed 6 actions needing review and updating by February 2025. The audit documents showed that these matters remained as ‘in progress’ at the time of the assessment. A health and safety audit undertaken in January 2025 rated this aspect ‘outstanding’. However, action from the previous audit were noted to have only been partially met.

All staff supervision audits submitted by the provider identified this area as ‘inadequate’. The audits ran from January 2025 to June 2025. There was no evidence that lessons learned in the January 2025 audit had been taken forward to address a wider supervision issue. Supervisions within the service were not methodically undertaken and the supervision matrix submitted by the provider showed significant numbers of staff had not received supervision this year. The provider told us that there had been no annual appraisals within the last 12 month. They stated this was a known issue. However, they did not provide a plan devised to address this issue.

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.

There was evidence in care records that staff worked closely with other professionals to deliver appropriate care and support to people. Staff spoke in detail about co-operative approaches to care and how they engaged with other health and social care professionals, to help progress people’s skills and improve their lives.

Professionals said the service was responsive to people’s needs and worked in a collaborative way to help people live meaningful lives. Comments from professionals included, “The home have an excellent relationship with [GP], I observed during our monthly MDT's an excellent working relationship between them and the staff. The staff also report regularly that they feel well supported by them and that they listen to their concerns without judgement.” and “I have observed good practice in relation to escalating concerns regarding resident's mental health, including use of MDT's, requests for review or further understanding the resident's conditions”

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.

Staff and the provider’s own training staff spoke about the range of training and experience available within the organisation. A staff member told us, “I’ve learned so much from working here. If you want to learn there is so much you can learn.”

However, there was minimal evidence of lessons learned within the organisation. Safeguarding records did not demonstrate that matters had been reviewed to consider wider implications when safeguardings occurred. Audit processes were not always followed up and there was limited evidence that issues highlighted in audit documents were considered across the service. Supervision and appraisals were not consistently undertaken and there was no plan in place to actively address the lack of appraisals at the service