Coundon Manor Care Home

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. This is the first assessment of this service under this new provider. This key question has been rated requires improvement. This meant the management and leadership was inconsistent. Governance processes 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 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 and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people. Staff worked as a team to ensure people received safe, effective and responsive care. One member of care staff told us, “We have good teamwork. We are all very amicable and we support each other. If you need help, there is always someone there. There have been several occasions when the carers are busy and the nurses step in.” Staff particularly commented on the positive impact of the new registered manager on improving the culture within the home. One staff member told us, “[Registered manager] has recruited better staff so better care is given.” A member of the management team explained how stability in the management of the home had helped develop a shared culture. They told us, “Coundon has been through a massive journey since it opened, it was not only the culture inside the home that needed work and changing. When you have managers changing it impacts on staff. Since [registered manager] started we have put some long hours in and worked incredibly hard because we want to see Coundon succeed.” New staff had a comprehensive induction to ensure they worked in accordance with the provider’s policies and procedures. One staff member explained, “When I started, I did shadow shifts, so I didn’t work on my own. I thought that was a good way for me to learn and it helped me feel more confident. The manager asked me if I felt ready to work on my own and that must have been at least 2 weeks after I started.” The registered manager told us they walked around the service every day to check on standards, observe staff practice and support staff when needed. They explained, “I feel I have gelled with the team. You should never be disconnected from your residents. You must know how to do the basics of care for people, and you should never be separate from that."

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. There was a management team with specific roles and responsibilities who worked well together. Staff told us the management team were approachable and supported them in their roles. One staff member told us, “I can speak to any of the mangers if I have a problem. They are friendly and approachable.” Another staff member said, “We have had a quite a few changes of manager, but I think this one is trying to get us to where we need to be, and I think she is interested in what we have to say.” One staff member explained the registered manager was caring but demanded high standards to ensure people’s needs were met. This staff member commented, “Since coming here I have felt welcome and supported. The manager is very kind and caring to the staff and residents. What I have also learnt is that she does not compromise on the residents. Everything has to be very good, and she will not tolerate anything less.” Staff had regular opportunities to meet with managers and senior staff to discuss their work and any development needs. A member of the management team told us, “Since [registered manager] has been here, the management team is more approachable. That is the first thing we really had to crack in terms of moving the home forward. If the team don't feel supported, how can they feel valued."

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had processes to support staff to speak up. This included supervision meetings, handovers and daily flash meetings. Staff told us they felt confident to share any concerns with senior staff and managers. One staff member told us, “I honestly think if I was worried about a resident, the nurse and the managers would listen, and they would be right on it, sorting it out.” A member of the management team explained the importance of feeding back when staff shared any information of concern. They told us, “Communication goes a long way with the team because if they feel listened to, that is a positive step in moving the home forward."

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 registered manager described a culturally diverse workforce who were supportive and respectful of each other. Where a need was identified, reasonable adjustments were offered to support staff in their role.

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. Managers completed daily walkarounds of the home but had not identified some of the environmental issues we found. Processes were not always in place to ensure the delivery of safe care. For example, there was no effective processes to ensure pressure relieving mattresses were on the correct setting, to review records relating to distressed behaviours and to ensure emergency services had accurate information about the people in the home. Where checks were delegated to others, there was limited oversight to ensure they were consistently completed and followed the provider’s policies and procedures. Some audits were not sufficiently detailed to ensure a robust system of checks. The provider carried out quarterly quality reviews of the service. The reviews checked audits had been completed but did not evidence the accuracy or effectiveness of those audits. We found information in the quarterly quality reviews was not accurate. For example, the quality review in January 2025 stated there were no building or maintenance issues or health and safety issues outstanding. However, there was a known and ongoing issue with the internal and water temperatures in the home. The provider’s oversight of complaints was ineffective. Quality reviews in October 2024 and January 2025 stated no formal complaints had been received which was not accurate. People and their relatives had not been asked to complete questionnaires or surveys and there was no evidence people’s experiences and outcomes were used to audit the quality of care provided. Processes to quality assure the service needed to be improved to identify areas for development and then used to create an action plan to further drive improvement at the service.

The provider needed more robust processes to demonstrate they always shared information and learning with partners and collaborated for improvement. Whilst people and their relatives generally demonstrated satisfaction with standards of care, most told us they were not aware of questionnaires or surveys and/or meetings in the home where they could share their feedback about the service. Where people had raised formal complaints, they were not provided with information about how they could escalate their concerns internally and externally if they remained unhappy with the response. The registered manager worked with other healthcare professionals and commissioners to ensure people’s needs were met and improve their outcomes. The registered manager had developed relationships with other groups in the local area to ensure people had spiritual and community support.

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. A culture of learning and commitment to improvement was demonstrated by the management team at Coundon Manor but this was not always supported by systems and processes. The provider needed to create additional and more robust checks to give themselves assurance they were monitoring the service effectively and continuously identifying when improvements were needed.