Ailwyn Hall

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 questionrequires improvement. At thisassessmentthe rating has changed toinadequate.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 regulationsin relation togood governance andduty of candour.

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.

Although the provider had a number of strategies they were putting in place to formulate a culture and vision for the service, these were not yet embedded and processes were not intuitive. Measures brought in to address recent whistleblowing and safeguarding issues at the service were not cohesive and new initiatives brought in by one person in the senior management team were not always fully understood or even known about at all by another. There was a lack of strategic planning with regard to taking the service forward. Staff told us the culture had been very poor in recent times, and many were still fearful to talk to us and share their experiences. Some staff praised the new management team and felt optimistic, recognising their willingness to take the service forward but others told us actions were not always in line with words and changes were hard to see.

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. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

When we carried out this inspection the service had just undergone an intense safeguarding investigation. The management picture at the service was disorganised. A new manager had just been appointed when we carried out our first onsite visit and they had not completed their induction. The deputy manager was off sick for a time and a number of senior staff, including the previous registered manager, had either left or been suspended. The regional manager had been in their role a few months and the service was being supported by a quality manager who had been in their role 2 weeks. Staff from other services run by the provider were also supporting the service alongside an external consultant. Individual staff were experienced, skilled, kind and compassionate but all were bringing in their own solutions to the serious concerns at the service and this created a very confusing picture which did not foster good and consistent care for people.

We identified multiple breaches of legal regulations and significant concerns across the service. The management team in post prior to and during our assessment process had not identified these and taken action to address them. Following our last assessment, which was published 02 June 2025, we imposed additional conditions on the service’s registration which required monthly updates to be sent to CQC. Senior staff completing these had often failed to complete these accurately and had not identified the serious concerns we found.

People did not feel they could speak up and that their voice would be heard.

Although some staff told us they felt more comfortable with the new management team and had been supported appropriately following the safeguarding investigation into abuse at the service, others remained very negative. We noted a hesitancy in some staff to trust senior staff, and some were not confident they would be fully supported should they raise a concern. This may have been a factor in why very few staff raised concerns about abusive practice within the service when it was taking place. We also noted some staff were fearful to share details with us and stated they feared reprisals by the provider.

Some staff had recently left, and others said they were actively considering this as they did not feel confident in the provider. One told us, ‘Staff do not feel supported and there is a poor culture here. It’s the same from when the last assessment was conducted. Nothing has changed,’

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had a diverse workforce, including staff sponsored from overseas. The vast majority of agency staff were from an ethnic minority background. The provider had not done enough to ensure these staff were fully integrated into the service and were able to work well with other colleagues. Oversight at a more senior level of how staff relationships at the service were managed was very poor and enabled a two-tier system within the staff team which could not be easily challenged. It remains unclear whether this was a factor in why staff did not feel able to raise concerns about alleged abusive behaviour carried out by agency staff.

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.

Roles and systems of accountability were not clear, and senior staff were not working cohesively leading to confusion and error. The provider’s processes for monitoring the quality and safety of the service were poor and often the provider’s own policies and procedures were not followed. A suite of audits had not identified the serious concerns we found and we identified both continued and new breaches at this assessment. Provider oversight of the service was not effective and spot checks and further investigation had not been undertaken appropriately to ensure information being sent to senior leaders and onward to CQC was accurate and complete.

There was poor oversight of staffing and the regional manager told us the rotas were ‘not fit for purpose.’ Throughout our 6- week onsite assessment process this did not improve. Management of agency staffing and their induction was still not robust despite the introduction of multiple new and reviewed systems. This was of particular concern given the serious safeguarding concerns which had been raised regarding agency staff. Recruitment records were incomplete in some cases, and this had not been identified by any provider oversight. Handovers were initially very poor but improved with some new processes being introduced. However, these were not followed in all cases.

Oversight of the environment was mixed with some good practice and clear records but also some poor systems and shortfalls which constituted a risk.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

Systems were not designed to enable the accurate and timely sharing of information with other healthcare partners. Staff were not easily able to find or log key information in a timely way. Although referrals were made to other health and care professionals, these were not always followed up, and the progress of any referral was not always clear to staff. Staff were not always clear when and even if referrals had been made.

There was a working relationship with the local GP service. However, we were not fully assured interactions were always beneficial to the people who used the service as the information shared with them was not always of good quality.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

There was little evidence leaders used information from incidents, audits or feedback to drive improvement. Systems to evaluate the quality of care and identify areas for improvement were not robust. A consultant had worked with the service in November 2025 and had returned in January 2026 to support the service with the safeguarding investigation and remained at the service. It was not clear how this has positively impacted the service.

We saw no evidence of innovation and the provider failed to find creative ways to deliver care and support. We found there had been an acceptance on the part of the provider of the unsafe and poor care which did not respect people’s preferences.