Littledale Hall Therapeutic Community

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

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 inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement.

This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

Governance process did not always operate as effectively or robustly as required. There were gaps in some documentation and governance processes where recording and completion were not always robust or ensured the service had appropriate oversight. In 1 of the 3 staff files sampled, there was no proof of identity including a recent photograph, which was not in line with requirements. There was evidence that staff discussed incidents within handover meetings although there were not always clear updates and records as to the resolution of incidents.

However, leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Performance and risk were managed well.

The service was in breach of regulation for governance at the service.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The evidence showed a good standard. The service 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.

Staff that we spoke with were positive about working for the service and the work that they were undertaking.

The service had a vision and values. When discussing these with the registered manager, they noted that they did not believe there had been significant changes to the vision and values since the service had opened, although they reflected that the philosophy and underpinning values were still relevant and essential to the service they aimed to provide. We reviewed a version of the service’s vision, mission and values which was dated 2021.

Staff could explain how they were working to deliver high quality care within the budgets available. Staff did not raise any concerns that budgetary restrictions impacted on client care.

The evidence showed a good standard. The service 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.

Leaders had the skills, knowledge and experience to perform their roles. The registered manager had been in post since 2022 and had worked for the service for a number of years before. The registered manager and nominated individual were both passionate about the service and ensuring that high quality care and treatment was being delivered to clients.

Leaders had a good understanding of the service they managed. They could explain clearly how the team was working to provide high quality care. Leaders were experienced within their roles and were open and honest when speaking about the service and receiving feedback.

Leaders were visible in the service and approachable for clients and staff. We observed positive interactions between leaders and both clients and staff. Staff gave positive feedback about the managers and the culture they aspired to achieve.

The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Clients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. The service did not undertake formal surveys of clients and carers but did offer the opportunity to give feedback on the service provided.

The service had feedback forms available for clients. As part of the treatment programme, clients participated in advice and guidance groups where they would complete slips on a daily basis to reflect on the previous 24 hours and any issues or feedback they may wish to share. The service also held a community group twice a day.

The registered manager noted that a family and carers feedback form was available but that the service received most of the feedback through letters and thank you cards.

The service had undertaken a staff feedback survey with a specific focus on management in 2025. Managers described that this had been a helpful process and could give examples of how they had made changes to their management styles and approach based on this feedback.

The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service promoted a culture of community and openness amongst the client group and staff.

Managers explained how staff would be supported in the workplace and how they would make adjustments if required. Managers felt that the staff team was supportive of each other.

Staff received training in diversity as part of the mandatory training programme.

The provider had various policies regarding equality, diversity and inclusion.

The evidence showed significant shortfalls. The service 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.

There were gaps in some documentation and governance processes where recording and completion was not always robust. For example, when reviewing the fire risk assessment that was completed in August 2025, there were 6 remedial actions identified by the reviewer. Whilst there was some evidence that actions had been taken to address these issues, there was no ongoing recording or oversight that the actions had been fully completed or where they were up to. There were also some examples of daily kitchen checklists not being completed, including 4 days missing from January 2026 and some gaps within the checks. Managers noted that the cook still needed to complete the end of month review of January's forms.

We reviewed 3 staff files during the on-site inspection. In 1 of the 3 staff files sampled, there was no proof of identity including a recent photograph. This meant that this staff record did not meet the requirements of Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was escalated to the service during the on-site inspection. The other 2 staff files contained photocopies of the staff member’s driving licence. The provider confirmed that this would be addressed immediately.

There was evidence that staff discussed incidents within handover meetings however, there were not always clear updates and records as to the resolution of incidents. During our review of handover notes, we identified incidents that had been recorded but, on subsequent days, staff had not recorded any updates or actions stating how the incident had been resolved or if there were still actions ongoing. It was therefore not clear that the recording and documentation of the handover process and discussions around the updates from incidents was robust and ensured that all staff would be aware of these updates and actions.

The service had not identified potential infection prevention and control risks in relation to furniture, which was ripped, torn or damaged, including a chair in one of the client bedrooms and the chairs in the office building. These were potential infection prevention and control risks as they would not have been able to be effectively cleaned in their current condition. The damaged chairs had not been identified within any of the service’s walkarounds or reviews of the environment. The service did not have a specific infection prevention and control audit.

The service held regular operations meetings which had a set agenda. This covered important areas of the service and ongoing business which enabled managers to have oversight of how the service was performing. There was evidence of actions being noted and updated as required.

The service had implemented learning and changes to improve the care and treatment provided. This had included a change to how life story work was completed within the service, which had resulted in a significant decrease of unplanned discharges.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the clients. External stakeholders gave positive feedback about how staff and the service engaged with them.

The service had a risk register which was dated July 2025.

The service had plans for emergencies. The service had a business continuity plan which was dated 2025. Although there was no specific date of next review recorded on the document, managers explained that this would be reviewed every year.

The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Stakeholder feedback was very positive about the service and how they engaged with external professionals and organisations. Stakeholders stated that staff were caring and were responsive to both clients and external professionals.

Stakeholders noted that communication with the service had improved over recent years and that they now received regular progress reports on individuals. They noted that, if any issues occurred, that they would be informed immediately.

Stakeholders praised the impact that the service had on the lives of clients, noting that the service had produced successful outcomes for many vulnerable individuals.

Stakeholders gave positive feedback about the aftercare provided by the service.

The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The service was a standalone service however, managers noted that they had built a close relationship with another local service to share practice, learning and get advice when required.

The service had a model of care which had been developed and embedded over a number of years that was having positive outcomes for those that were admitted to the service. Stakeholders that we spoke to held a high opinion of the service and the impact it had on the local area.