Archived: 23 Perryn Road

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 good governance and notifications.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always work in line with CQC’s Right Care, Right Support, Right Culture guidance. Evidence from audits, safeguarding records, incident logs and care planning showed people were not consistently protected from harm and governance systems did not reliably identify or address risks.

People’s care plans showed some person‑centred practice and involvement in activities. However, this was undermined by outdated records. Mental capacity assessments and Best Interest decision processes were incomplete. Follow‑up on health screening and risk‑related actions was also missed. These gaps meant care was not always delivered in a safe, least restrictive or empowering way.

We found further cultural concerns within the service. Staff meeting minutes showed recurrent issues with documentation, medicines errors and financial oversight that had not been addressed despite repeated discussions. A report on a recent fire drill described it as “chaotic” and highlighted poor leadership and missed basic safety steps, demonstrating a lack of accountability and preparedness within the team.

The service had experienced a period of instability in leadership, with frequent changes of managers over a 4 month period and no CQC registered manager in post since the departure of the previous registered manager. Despite this, there was evidence the provider continued to oversee the service during this period to maintain safety and continuity of care.

Feedback from relatives, however, showed mixed experiences of management, reflecting the impact this instability had on the culture and day to day leadership of the home. A relative described previously having strong communication with the registered manager but felt this had declined, noting that staff changes, and reduced updates meant they no longer understood “what’s happening” in the home.

Another relative, described some earlier positive experiences with the former registered manager but highlighted that management changes and staff turnover had affected consistency. Although they felt staff remained polite and supportive, they noted communication and involvement in reviews were limited.

The inconsistency in leadership meant relatives experienced reduced communication, limited involvement and declining confidence in how well the service was being managed, affecting their sense of trust and connection with the home.

The provider had a whistleblowing policy in place; however, we were not assured staff felt able or supported to use it. The persistence of incomplete, delayed or off system incident recording indicated staff did not always escalate concerns or may have felt unable to do so consistently.

Multiple audits and oversight records showed unreported incidents, missed safeguarding escalations and gaps in daily documentation, suggesting staff were either unclear about reporting expectations or reluctant to raise issues through formal channels.

Feedback was sought from people and relatives but failed to capture the concerns relatives had shared with us during this assessment. A relative described a decline in communication and oversight, which may have reinforced a culture where challenges or concerns were not openly welcomed. Staff had also not consistently followed expected escalation processes in safeguarding incidents and governance matters, such as medication errors and repeated unexplained injuries.

This evidenced a culture in which staff may not always have felt confident, supported or empowered to speak up, and where concerns were not consistently escalated, acted on or learned from. This limited the provider’s ability to identify emerging risks, protect people from harm, and maintain a transparent and open safety culture.

The provider had an Equality, Diversity and Inclusion (EDI) policy that clearly outlined expectations for fairness, respect and equal opportunities, and set out responsibilities for leaders and staff to promote inclusion and eliminate discrimination. However, evidence from the service showed these principles were not consistently embedded, with gaps in practice relating to training, competence and workforce oversight.

Supervision records showed, while some staff received structured 1-1 support, this was not consistent across the team. Key issues such as missed incident reporting, gaps in mandatory training and repeated recording failures, continued to appear in staff meetings. Although safe recruitment checks were completed, these could not compensate for the lack of effective, ongoing supervision. As a result, staff confidence, escalation of concerns and adherence to expected behaviours remained variable and poorly supported.

Relatives also described the impact of workforce instability and staff turnover, noting a reduction in communication, fewer updates and inconsistent staff knowledge. Overall, while the provider had strong policies and some positive elements of staff support, the workforce lacked stable leadership, consistent supervision, and fully embedded EDI principles, contributing to broader weaknesses in governance and service quality.

Governance arrangements at the service were not consistently effective. Although audits, checks and staff meetings were in place, they did not reliably identify or address risks. Monthly audits in areas such as fire safety, food safety, infection control and contingency planning showed repeated shortfalls, including incomplete risk assessments and environmental concerns. Clinical governance was also inconsistent, with medicine audits identifying recording errors and missing mental capacity documentation.

Systems for incident reporting and safeguarding were not always reliable, with delays in recognising and escalating concerns and missed opportunities for learning. A recent organisational safeguarding referral identified wider issues including incident non‑reporting, documentation gaps and financial governance concerns. Despite concerns being raised in staff meetings, several issues continued to reoccur, showing learning was not always embedded.

Quality audits also identified overdue risk assessments, gaps in daily records and maintenance actions that had not been escalated. Although people and families provided positive feedback through the provider’s “Your Home Your Say” survey, this did not align with what relatives shared with us during this inspection and there were persistent weaknesses in safety monitoring and compliance.

Approximately 1 month before our inspection, the local authority began formally supporting the service due to governance concerns and increased risk of harm to people using the service. A joint improvement plan had been put in place, and the provider has since notified us of their intention to close the service. Work was underway with local authorities and health professionals to support people to move safely to alternative accommodation.

Health Action Plans (HAP) and support plans demonstrated the service worked with a range of external health professionals, including GPs, opticians, dentists, nurses and learning disability health teams. A person’s HAP showed involvement from their GP, vaccination services, opticians, dental care and historic referrals for ear irrigation. The HAP also referenced positive behaviour support input and adjustments relating to communication and mental capacity.

Another person’s care plan evidenced wider multi‑agency involvement, including the community learning disability team (CTPLD), nurses, GP, and their care manager. The care records showed engagement with hospital professionals for desensitisation sessions, vaccination support, and ongoing health checks.

Both care plans showed people were supported to attend appointments, and staff sought advice from external health professionals when needed. Screening, dental care, behavioural support and medication advice appeared within records, which showed external health information were included in care plans.

The level of partnership working was inconsistent. Some screening entries were marked as refused or not completed without clear documentation of follow up, alternative approaches or evidence of further professional input. Not all health recommendations were cross referenced to up-to-date assessments, and some actions lacked detail showing how external advice was reviewed or embedded in daily practice. This meant that while partnership working was present, it was not consistently applied or fully assured.

Senior management had begun a review of the service, and a service improvement plan was in place. However, the plan did not include all the issues we had identified during inspection, and gaps in incident reporting limited the provider’s ability to analyse trends, learn from events and embed improvements. As a result, good practice was not consistently identified or sustained.

The provider operated a staff recognition and reward platform, which enabled staff to earn points through internal recognition schemes and redeem these for products and benefits. The provider informed us that these recognition related benefits were separate from the wider employee benefits available to all team members through the organisation’s benefits schemes.

Staff meeting minutes from January 2026 showed a focus on improving the quality of incident reporting. The provider had also introduced mobile enabled incident reporting software to make it easier for staff to record events in real time. This reflected a problem-solving approach and a commitment to standardising information to support learning and analysis.

Following our feedback, senior management updated their plan to include additional concerns identified during the inspection. This demonstrated a willingness to respond to regulatory feedback and strengthen the service’s approach to learning and improvement.