Delamere Lodge

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 requires improvement. At this assessment the rating has remained the same. 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 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 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.

Staff described a positive culture. Staff told us they felt part of “one team” and described the manager as approachable and supportive. One Staff member told us, “The manager is a sweet soul” and that they worked well together to help people.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always lead effectively, or they did not always take immediate action to identify and resolve issues.

Leadership was visible and committed to improvement. Area managers and the provider were regularly present. The new manager was described as kind, supportive and motivating by many staff. However, managers audits didn’t always take immediate action to resolve issues found during this inspection.
 

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

Staff felt comfortable raising concerns and described a culture where issues were listened to and acted on.

Staff stated they would speak up if they witnessed poor practice and were confident the manager would act, with one staff member saying they would even “go to the owner if needed”. Staff described regular opportunities to share issues at meetings and said feedback was encouraged and acted upon.

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 felt they were treated fairly and reported an inclusive working environment, one staff member told us, “It is a fair place to work” and that both staff and people using the service were treated equally. None reported experiencing or witnessing discriminatory behaviour.
 

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. Systems for oversight and governance were in place, but they were not always effective in identifying or addressing recurring issues relating to safety, cleanliness, mental health care planning, and record accuracy.

The provider undertook audits, including care plans, medicines, and health and safety, and recent months showed improved compliance and action planning. Monthly governance checks were in place. However, audits did not consistently identify ongoing shortfalls that inspectors found, such as cleanliness issues and gaps in mental health care planning.

The service did not always act quickly enough when audits or external feedback identified gaps. For example, provider audits throughout 2025 repeatedly highlighted gaps in staff supervision, training and fire safety records and timely progress was not always seen.

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.

The service engaged in community activities including, Healthwatch consultations, charity events, and planned wellbeing activities, with evidence of positive experiences for people. However, the service was required to have a service user band registered for supporting people with mental health conditions and this had not been identified by management prior to our inspection.

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.

Leaders had taken steps to improve after incidents, but learning was not always consistent, and some issues had not been effectively addressed.

The service introduced more frequent audits, improved governance checks and strengthened management oversight following concerns raised. However, issues persisted, including infection prevention, and care planning updates.