Archived: College House

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 inadequate.

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 provider was in breach of legal regulation in relation to consent and governance.

This service scored 36 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Shortfalls identified within this assessment in relation to consent and person-centred care did not demonstrate a culture which had a joined-up approach, and care provision failed to be informed by the relevant legal framework and best practice.

Due to a lack of mental capacity assessments in line with Mental Capacity Act 2005, the service could not be assured people’s human rights were being upheld.

Audits and improvement plans were outdated, and the registered manager had not identified significant shortfalls, such as missing risk assessments for environmental hazards and gaps in governance processes.

This contributed to the breach of regulation in relation to consent to care and treatment and good governance.

While some staff described working together and supporting people as a “family”, this was not underpinned by professional standards or structured leadership.

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.

The provider did not identified the learning needs of the registered manager, and the registered manager did not identify their own learning needs and had not ensured they addressed gaps in their own knowledge. This meant they were not aware of relevant guidance to support safe, high-quality care and treatment. For example, they were unfamiliar with the‘Health and Safety in Care Homes’guidance published by the Health and Safety Executive in 2014. This had resulted in significant safety issues being unidentified and associated risks not being managed.

While the registered manager worked on the floor and was approachable to some staff, there was limited oversight of governance processes. Audits for medication, daily notes, and health and safety were either overdue or not completed since May 2025.

Staff reported rotas were often unfair and issued late, and some felt communication was poor.

This contributed to the breach of regulation in relation to good governance.

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

The provider did not always encourage an open culture where staff felt confident to raise concerns. While most staff said they would escalate safeguarding issues if needed, several reported the management team did not actively promote speaking up and staff meetings were infrequent, with concerns sometimes being dismissed by the registered manager in meetings.

Some staff felt their feedback was not acted upon, and meeting minutes were not consistently circulated. Staff commented the registered manager was dismissive and failed to act when they raised concerns about rotas and made suggestions that may improve outcomes for people.

There was no evidence of a robust whistleblowing process being shared or understood by staff.

We observed a person arranging a meeting with the registered manager to raise concerns. We did not see any recorded evidence of concerns being raised by the people living at the service and appropriate action being taken, when required.

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

The provider had policies on equality and diversity, last reviewed in October 2023. The document did not include a planned review date, so the provider could not be assured it was reviewed regularly.

Training records showed gaps in key areas, including autism awareness and challenging behaviour, which are essential for supporting people with learning disabilities. This meant there was a risk that people living at the service may not receive care and support in line with current recognised best practice.

Staff reported issues with rota fairness and inconsistent treatment, and there was no evidence of a workforce equality strategy or monitoring of reasonable adjustments. There was no evidence of reasonable adjustments being systematically recorded.

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 registered manager told us, they were behind on their auditing, and did not have oversight of audits completed by other staff members.

Governance systems were ineffective. Key audits (medication, infection control, daily notes) were overdue, and there was no evidence of learning from incidents or medication errors.

The provider did not have systems and processes to manage environmental risks, such as legionella checks and radiator safety, and the registered manager lacked awareness of Health and Safety Executive guidance.

Care plans and risk assessments were undated and not reviewed regularly, creating risks for people with complex needs.

Records were not contemporaneous, and care plans lacked essential information, including mental capacity assessments and end-of-life preferences.

Due to these shortfalls and lack of oversight, the provider cannot be assured systems and processes operate effectively to make sure they assess and monitor the service against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This contributed to the breach of regulation in relation to good governance.

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.

The service worked with some external professionals, such as GPs and epilepsy nurses, and people were supported to attend health appointments. There was limited evidence of collaborative working with local quality teams or engagement in community initiatives.

We received some positive feedback from professionals, such as, “The staff at College House are true advocates for their residents and it is a pleasure to visit”, and “The staff at College House have a good knowledge of the people they care for and appear to support their health needs appropriately”. However, information from professionals was not always being followed, putting people at risk of their assessed needs not being met.

One safeguarding incident and a physical assault were not notified to CQC as required. We discussed this with the registered manager, who has completed these notifications since our onsite assessment.

Following our assessment, the registered manager has been supported by the local quality team due to the level of concerns.

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.

There was little evidence of a learning culture. Incidents were not investigated or recorded systematically, and lessons learned were not shared. Medication audits identified issues but were not followed up, and staff competency checks were reactive rather than proactive.

The registered manager acknowledged gaps in knowledge and governance and had not implemented service improvement plans.

The registered manager had reviewed surveys sent to families in December 2024 and identified action was required, however there was no evidence of concerns being addressed.

This contributed to the breach of regulation in relation to good governance.