Ornate Health Care Derby

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 newly registered service. This key question has been rated required 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.

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.

The leadership team showed an open and transparent approach. They promoted a positive culture and support. Feedback was gathered from people using the service, relatives and staff to drive improvements where needed.

[RR2]amended

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.

We found leaders responsive to the information we requested. Staff told us they found the management team approachable and supportive. A staff member said, “Yes, I feel supported in my role. The managers are approachable and ready to provide support, if I’ve got concerns, in doubt or need advice, I can ring or meet with them any time.”

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

Whistle-blowing procedures were in place, ensuring there was a culture where staff could raise issues. Staff told us they felt able to raise concerns and were confident these would be acted upon appropriately by the management team. A staff member said, “Yes there’s a positive culture where I can speak up when necessary. I have raised concerns and have been listened to.”

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 were given opportunities to develop through regular supervision, staff meetings and training. Polices were in place which promoted equality and diversity in the workplace.

The provider did not always have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider’s current audits were not effective at identifying shortfalls and driving improvements in the quality and safety of the service. For example, they had not identified all of the issues we found on our inspection, which were raised with leaders.

Systems and processes were not always effective to ensure notifications required to notify CQC of certain events and incidents were submitted to CQC. They are important as they help to show the provider is working in a transparent and open way. We found examples where notifications had not been submitted and discussed this with leaders who completed these retrospectively.

Reviews of accident and incidents showed that these were not always reported externally such as the local authority. We found 2 incidents had not been escalated to the local authority. We discussed this with leaders who took immediate action and reported these retrospectively.

Medication management records were not always clear about the level of support staff were required to provide. This meant staff did not always have the information they needed to consistently deliver safe support with medicines.

Some policies we reviewed were not up to date. Leaders took immediate action to update these once we raised the issue. However, this showed the provider’s governance systems had not identified the shortfall and were not always effective in ensuring policies remained current.

The provider had a quality improvement plan in place; however, the version we received was dated 22 July 2024, and it was not clear whether the identified actions had been completed or updated since that time.

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.

Leaders told us that guidance and support were sought from external health and social care partners as required. The provider had been engaging with the local authority following the last quality audit monitoring visit during September 2025.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. During this inspection we found leaders had a lack of oversight of the service, due to the shortfalls we identified. However, leaders welcomed our feedback based on this inspection and took immediate action to address or clarify issues we identified during our inspection.