Heartly Green

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 of the service.

This service scored 61 (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 have a clear vision, strategy and culture, but if this had been shared with staff it wasn’t apparent in our conversations with staff. We did not see any references to the provider’s values on display in the service, although these were communicated to staff in team meetings.

People, relatives and staff we spoke with told us of the service improvements since the new manager had been in post. The manager and deputy manager were working hard to implement systems and improve practices and processes within the home.

We judged the leaders at the service had the skills, knowledge, experience and credibility to lead effectively and they were working towards improving the delivery of care.

At the time of our inspection, the manager had been in post for approximately 5 months. They gained registration with the Care Quality Commission (CQC) on 27 May 2026, immediately after our onsite visits. Prior to this there had been no registered manager in post for over 3 years. The manager was supported by a long-standing deputy manager, and the regional manager was also present during this inspection.

People and relatives we spoke with outlined to us the positive changes that had been introduced by the new management. Staff we spoke with also shared positive feedback about the manager. We found the new management team were responsive, supportive and welcomed feedback and constructive criticism but a lack of robust systems and processes meant we could not be assured concerns would be identified and rectified independently.

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

Staff were provided with opportunities to voice their opinions or raise any concerns they might have. There were regular meetings, supervisions and audits of staff practice. Staff meetings and handovers were also mechanisms for information sharing between staff undertaking different roles in the home; these ensured important information was cascaded to others to help drive improvement.

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.

The management structure had seen some recent changes; staff told us communication from them was much improved; staff felt included and involved. Staff indicated the culture of the service was improving and they felt confident in the new management team.Staff told us there was more praise and recognition, which made them feel valued. A member of staff told us, “She’s (the manager) part of the team; she's always around when if you need her (and is) involved in the group.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance and the service had been without a registered manager for a considerable period of time.

The service completed audits, however these did not always identify shortfalls, when they did, these were not always addressed in a timely manner, and they had had not been effective in identifying the issues found on the inspection.

On our third day of inspection the regional manager’s audit identified a medicine administration error, as a time-specific medication had been given early. Medicine administration errors were a common theme that the provider, partner agencies and the CQC had all identified. Staff were not following the policy to ensure time-sensitive medicines were given as prescribed. Staffs' medicines competency assessments showed that not all staff had access to the medicines policies or had been assessed as competent to administer all types of medicines.

Medicines policies were not always followed to ensure medicines were managed safely, for example the monitoring of fridge temperatures to ensure medicines were kept at the required temperature and therefore safe to use. Staff practice and training in the administration of medication needed to improve, along with systems and record keeping in relation to care planning information, so management were assured people remained safe.

A bank member of staff started an afternoon shift on our second day of inspection; they had not worked at the home for 8 weeks. There was no handover or information shared with them prior to starting their shift. Given the changes in people’s needs that might have occurred since they last worked, we brought this to the manager’s attention. The manager introduced a handover for staff coming onto shift in the afternoon to ensure they were briefed about any new admissions and changes to people’s care and support needs.

Where partner agencies had identified any improvements in practice, for example with infection control, these were being closely monitored to ensure sustainability going forward. Although the provider had a service improvement plan and management were responsive to concerns raised, there continued to be exposure to the risk of harm for people at the time of our inspection.

The provider was aware of the shortfalls in the service, and the manager submitted evidence of action taken to improve oversight going forward. There was further support for the manager with weekly meetings with the managing director and monthly meetings with the nominated individual.

We saw evidence of the service working with partner agencies but judged that this was not always consistent. We received feedback from partner agencies that the service was engaging with them to make service improvements.

There was partnership with the community; items were being donated to help improve the outside spaces for people. Children from the local nursery also attended the home with pre-arranged visits.

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.

The provider was working to improve their focus on continuous learning and improvement and had a service improvement plan. We saw examples where learning was shared and discussed, for example, in staff meetings and daily ‘huddle’ meetings. Although we saw some evidence of lessons being learned and the manager demonstrated a clear desire to improve the service, processes needed to improve to ensure any learning could be effectively implemented and embedded in practice by all staff.