Deepdene Care Centre

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 service 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 and relatives were overall positive about the management team. Their comments included, “The manager is always available if we need to see [them]. [They are] keen to get the standards up” and “They do have regular relatives’ meetings here and they report back afterwards on what action has been taken. They update us on staff matters and things like that. The staff situation has improved now and they do not use any agency now.”

The management team was visible in the service, approachable and took a genuine interest in what people, staff, relatives and professionals had to say. The management team carried out occasional night visits, to help ensure the standards of care reflected people’s needs. We saw one carried out on 24 January 2025. This did not highlight any concerns.

The management team worked hard to instil a culture of care in which staff were valued and promoted people’s individuality, protected their rights and enabled them to thrive. We were assured that prompt action was taken when we reported concerns following our visit. Staff told us there was a good and positive culture within the home. A member of staff told us, “I like working here because I have felt accepted by all the staff, who smile and say hello when I see them which makes for a happy working environment.”

The registered manager set a culture that valued reflection, learning and improvement. The management team effectively used staff supervision and regular team meetings as a platform for staff to raise any concerns and an opportunity to share their views and opinions.

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. Overall, people and relatives were positive about the management team, and thought they had the skills, knowledge, experience and credibility to lead effectively. One person told us, “If I had a problem I would tell (Deputy manager) – [they are] a nurse.” Staff found the management team to be visible and supportive. Their comments included, “I am only in my fourth month working here and I have found the managers to be kind and supportive at all times” and “I receive adequate support from my colleagues including the manager and regional management teams. My views and ideas are listened to, and I receive feedback about my efforts which makes me feel valued.” Other meetings included daily flash meetings, weekly governance meetings, staff meetings, meetings for people who use the service and health and safety meetings. Discussions included care issues, health and safety, policy awareness and review, values, dignity, and quality assurance. Clinical meetings were regular and included a review of each unit. Subjects discussed included any changes in people’s health status, any concerns from people or relatives, falls and mobility, accidents and incidents, near-misses, safeguarding and new admissions.

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

People and relatives felt included in the culture of the home and were invited to share their views of the service through regular meetings and yearly surveys. The results of these indicated people were happy living at the service.

Staff told us they knew about the provider’s whistleblowing policy and would not hesitate to use this to benefit people living at the home. One staff member told us, “I would feel able to whistleblow if necessary… I would tell the home manager but if that was not feasible, I would contact the regional director or phone the whistleblowing hotline. I could also contact someone externally such as the CQC if I didn’t feel able to raise a concern internally” and another said, “I was also encouraged and reminded to read and sign the whistleblowing policy.”



The provider had some processes in place to support staff to speak up. This included supervision meetings, handover meetings and staff meetings. Staff had also received training in safeguarding to reinforce their understanding and their responsibility to speak up.

People were given information when they moved to the home about how to raise a concern. Records we viewed indicated complaints were recorded 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.

The staff we spoke with were positive about their experience of being recruited and working at the home. Staff told us they felt supported by the management team. For example, they were able to make a request in relation to childcare issues or appointments and this was always considered.

The staff team was diverse, and most staff came from different parts of the world. Diversity was celebrated at the home. For example, Halal food was supplied for a person. Activities organised took into consideration people’s religions and beliefs. The provider celebrated the different festivals and cultures.

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 provider’s monitoring systems had not always been effective as they had failed to identify the concerns we found during our inspection. Medicines audits completed had not identified the concerns we found in relation to medicines management. Although there were measures in place to assess risk and protect people with high needs, these had not been effective enough to protect people from the risk of harm. Our findings in relation to poor care witnessed during lunch time had not been identified by others, and there was a risk that this was considered normal by staff. This put people at risk of harm as mitigation had not been implemented. We fed back our findings to the registered manager.

The staff told us they felt supported by the management team and liked working for the service, They told us the managers’ doors were always open and they could discuss any concerns they may have. Their comments included, “I am happy working here. It’s a good place” and “We get the chance to discuss things during meetings. I like my job and the people we care for."

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.

People told us they had access to health professionals including the GP who visited regularly. Relatives said they were kept informed of any changes to their family members’ care. People’s care plans recorded where referrals had been made, and where people received follow up appointments. Healthcare professionals told us they had a good working relationship with the management and staff.

The deputy manager told us they had developed an effective working relationship with external professionals to help ensure people’s needs would be met. This included the local GP practice, speech and language therapy team and the local church. They also had a few volunteers who brought lap dogs which people who used the service enjoyed. They added, “We try to partner up with [Dementia organisations]. We also have local colleges come to the home for work experience. The local hospital care liaison team help with assessments. They give us feedback if a person is currently in hospital. They liaise very well with the home.”

Healthcare professionals who visited Deepdene Care Centre were complimentary about the management team. One healthcare professional told us, “Generally, I am very satisfied with the support provided for my client's care needs.”

The provider had systems and processes to ensure people’s needs were reviewed with external professionals. The provider listened to feedback from them and where a need was identified, amended their policies and procedures to promote effective communication and partnership working.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe and effective practice and research. They acknowledged where improvements were needed and therefore had reinforced their monitoring systems following a recent serious incident.

People were consulted individually during reviews or conversations, or as part of a residents’ meeting, to find out if they had any concerns or requests. We saw people’s opinions and requests were taken seriously. We saw a range of compliments received from people and relatives. Comments included, “Thank you for all the love and care you gave my [family member], [they were] so happy with you” and “We have been impressed and appreciative of the care and consideration that you and your staff gave [Family member].”

The deputy manager told us they were always looking at ways to improve as a service to help meet people’s needs and improve their lives. For example, following a continence assessment, it was advised to use decaffeinated tea for people to reduce the need to use the toilet, therefore to reduce falls. An analysis had showed a 20% to 30% reduction in falls.

Two of the nurses had completed “Care excellence training.” The aim of this training was ‘How to improve and excel in everything you do’. The provider was now planning for more staff to undertake the training.