The White House

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 for this provider at this location which they took over from the previous provider in July 2024. This key question has been rated Inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care. The service was in breach of legal regulation in relation to the lack of robust governance at the service and notifications not being sent to CQC as required. There was a lack of robust oversight of the safety and quality of care. Staff said they felt supported by the manager and deputy manager but did not always feel valued by the provider. There was a lack of systems in place to gain feedback from people, relatives and staff.

This service scored 25 (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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities. Quality frameworks did not always recognise best practice and were not effective in identifying short falls in the care people received or gaps in people’s care records. The provider told us, “After the purchase when I walked into the home first time I was shocked with the state of the home.” Despite this, they continued to admit people into the home. Although some works had been undertaken, the provider had not prioritised areas of the highest risks. The provider had allocated their maintenance member of staff to work on refurbishment of a part of the service that people were not living in. They did not consider this member of staff was needed in the part of the home people were living to undertaken checks to ensure the safety of the environment for people. The provider failed to recognise they had developed a culture that did not robustly promote or uphold people’s rights. After our visit to the service on 4 March 2025, we were informed the provider had been contacted by a member of staff around alleged safeguarding concerns in January 2025. However, the provider failed to take any actions in relation to this and the alleged abuser continued to work in the service until after our inspection without any investigation taking place. The provider did not have a robust strategy in place to ensure people lived their home that was free from strong odours and was a safe environment.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. The provider had not formerly met with all staff that were already working at the service when they first purchased it. There had been no meetings with staff to discuss the plans moving forward. When a new manager started in February 2025, this had not been discussed with any staff until the managers first day. A member of staff told us of this, “I did feel undervalued.”

There were staff who felt the leadership team were inclusive and valued diversity. However, there were other staff who felt there was a lack of equality in how they were treated. Some staff fed back their frustration on continuously raising where improvements were needed and felt ignored. More work needed to be undertaken to create a working environment and culture where every member of staff could experience a sense of belonging and empowered to achieve their full potential. However, the new manager was doing all they could to try and address this and we saw them trying to assist a member of staff with some personal concerns.

There were staff who felt the leadership team were inclusive and valued diversity. However, there were other staff who felt there was a lack of equality in how they were treated. Some staff fed back their frustration on continuously raising where improvements were needed and felt ignored. More work needed to be undertaken to create a working environment and culture where every member of staff could experience a sense of belonging and empowered to achieve their full potential. However, the new manager was doing all they could to try and address this and we saw them trying to assist a member of staff with some personal concerns.

The provider’s governance systems were inadequate and failed to recognise a range of shortfalls in people’s care and the service. The provider failed to identify through audits that decision specific mental capacity assessments had not been undertaken when required. There was no evidence of how people’s best interests had been considered and how decisions were made to ensure least restrictive support. The provider was unable to provide evidence of an effective system to assess, monitor and improve the quality and safety of the services provided and to ensure they had met the regulatory requirements. The provider also failed to submit safeguarding allegations to the CQC where appropriate.

Whilst staff within the service were effective in sharing health concerns about people’s needs, the provider had not taken steps to with partners to address the concerns around the continence concerns people had. The provider was aware that a high percentage of people required referrals to the continence team but there was no evidence the provider had taken action to assist staff with these referrals by providing appropriate equipment to scan essential documents. The provider had continued to admit people without fully consulting with the funding authorities about whether this was appropriate given the safety concerns they had still not addressed within the service. The provider also failed to share safeguarding concerns with the local authority

The leaders did not focus on continuous learning, innovation and improvement across the organisation and local system. There was no analysis of the overall incidents to look for trends, themes and triggers to try and reduce the risk of incidents which placed people at risk. By reviewing incidents, this can leave to implementing changes that lead to continuous improvement. This might involve reviewing the deployment of staff and enhancing staff training that reduce the likelihood of future incidents. We found this was not taking place. There was a lack of analysis of behaviour charts to understand people’s triggers. Whilst there was a staff team that was passionate about delivery safe and effective care to people and had lots of ideas about how improvements could be made, there was a lack of action by the provider to consider these and implements the changes.