Hoyland Hall Residential 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. 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.

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.

Staff and leaders 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. Staff and leaders could not explain what the provider’s values were and therefore were not part of a shared culture. People were not always included in decisions about their care, and their independence was not always promoted.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. Leaders had not always supported staff to deliver safe and effective care which met people’s needs and improved their outcomes. Staff and leaders had not consistently investigated and reported concerns to appropriate external bodies to ensure openness and transparency. We found concerns which should have been reported to the local safeguarding adults service and the CQC.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a whistle blowing policy in place and staff felt supported to raise concerns.

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 told us they felt supported, but some training was not up to date. The provider had a schedule in place to address this.

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, or share this securely with others when appropriate. The management team were disorganised and did not have information readily available. The management team did not have a good overview or insight of the service. Audits in place did not identify concerns we found during our assessment in relation to safe care and treatment, medicines management, safeguarding, person centred care, IPC and good governance.For example, the last medicine audit had been completed in December 2025 and therefore no recent medicines audit had identified the issues we found during our inspection. The last IPC audit completed in January 2026 scored 97%, this was not in line with our findings. The health and safety audit had not identified the issues we found regarding the safety of the environment. Following our inspection the provider took appropriate actions to ensure governance in the service improved.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. Where people had been referred to healthcare professionals, there was limited information to evidence their advice had been followed. There were limited opportunities for people to interact as part of the community.

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. They did not always actively contribute to safe, effective practice and research. At our last inspection the service was rated good, however, the at this inspection the service had deteriorated to requires improvement. The service showed signs of deterioration and a lack of learning had taken place. For example, accidents and incidents recorded were not always analysed to ensure trends and patterns were identified to mitigate future risks. This reduced opportunities for learning and improving care and had a negative impact on the quality of service offered to people living at the home. The provider sent us an action plan setting out their intention to improve the service.