Heathlands Care Centre

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 inadequate. 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.

At our last four inspections, the provider was in breach of the legal regulations in relation to the management oversight and governance of the service. At this inspection, we found that although improvement had been made, the provider remained in breach of this regulation as increased oversight and governance were required.

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 staff team shared a vision, strategy, and culture, and understood the challenges and the needs of people and their communities. There was a positive atmosphere within the home, with people and staff appearing to be relaxed and trusting of each other.

People and their relatives told us significant improvements had been made to the culture and atmosphere within the service. Comments included, “Nothing needs sorting out now. [Manager] has done amazingly. [Manager] is very, very, innovative and now all the carers here are excellent.” And, “The atmosphere here has changed completely [for the better].”

The service had worked with people and staff to develop clear values which were displayed in the home. In addition, staff working practices had also been developed in areas such as good communication and supporting people with their personal care. Staff told us the additional support and focus on having an open and transparent culture had given them confidence in their roles. One staff member told us, "It is now dominated by staff who are doing from the heart. Staff sometimes need reminding to take a break as they just keep going because they enjoy it. There is no clock watching.” The manager told us they were proud of what the service had achieved, “Changing the way staff work, and the culture has been the hardest thing. We have achieved it by working together and making staff understand we work on trust.”

Systems had been introduced to increase people’s involvement in the running of their homes. For example, the role of resident ambassadors had been introduced and was being embedded in practice. Ambassadors had been involved in choosing furnishings, and processes to involve people in staff recruitment were being implemented.

Not all leaders understood the context in which the provider delivered care, treatment and support. Whilst feedback from people, staff and professionals regarding the manager of the service was consistently positive, there were on-going concerns regarding the lack of oversight from the provider.

There was a lack of management presence and support in the service, with the manager as the only leader on-site. Although attempts had been made to employ a deputy manager, the provider told us they had not found the right person for the role. However, they had not considered what additional interim measures could be taken to ensure the service was fully supported.Records showed that there had been regular on-site support from a management consultant, who was also employed as the Nominated Individual, until September 2025. This had significantly reduced after this time, with the majority of support being via email and telephone. This meant the manager was responsible for all aspects of the running of the service, the clinical oversight of a new nursing team, and liaising with professionals. This was in addition to ensuring the required improvements were fully implemented and embedded into practice. The manager told us this had led to elements of the quality assurance processes, such as completing audits, falling behind.

The local authority had continued to provide support for the service by employing a consultant who was regularly based at Heathlands for 3 full days a week. Findings of their observations and document reviews were shared with the manager and the local authority to measure progress and ensure the service continued to operate safely. The local authority told us at the time of our inspection that they had not felt able to withdraw this resource due to the lack of oversight and management presence from the provider.

Following the inspection the provider informed us they had employed a deputy manager and onsite support from the Nominated Individual had increased.

The provider fostered a positive culture in which people felt they could speak up and have their voices heard. People, relatives, staff and professionals told us they would feel comfortable in raising any concerns or making suggestions to the manager. One relative told us, “[Manager] is very open to suggestions and we know [they] would do the best [they] could.”

The provider had requested regular feedback from people and their families. Surveys showed people and their relatives felt there was a significant increase in quality of the care they received. Survey results in February 2025 raised concerns in most areas reviewed with frequent references to staff not having the skills needed. In contrast, the survey completed in September 2025 showed that people and their relatives felt their views had been listened to and that improvements had been made. This had led to an increased confidence in the service people received.

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 said they felt they were treated well and their concerns were listened to. One staff member told us, “We used to have different staff groupings [from different cultural backgrounds] who didn’t work together. Now we don’t see that, and everyone is treated the same.” A second staff member told us, “They have helped me with the rotas. I think everyone feels equal and able to ask for what they need now.”

The manager told us they had a variety of support systems for staff, including flexible working arrangements and task management. They told us, “We have taken a lot of time to get a good team, we want to keep them. I will listen to requests, and we can look at how to fit it in with the needs of the residents.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance.

There was a lack of consistency in some areas of the quality assurance processes. Audits and reviews were taking place in some areas which had led to improvements in the care people received. These included the on-going monitoring of accidents and incidents, safeguarding, medicines, infection prevention and control and clinical risks. However, we found that audits and regular reviews were not always completed in other areas. This had led to continued shortfalls in the quality and accuracy of some documentation and systems, which had not been identified or acted upon. These included records relating to risks to people’s safety, personalised care plans, monitoring of environmental hazards, and support for people in the administration of covert medicines. In addition, we found that increased oversight was required of records relating to the Mental Capacity Act 2005 and staff recruitment files. Whilst improvements had been made in all the above areas, the lack of consistency meant the provider continued to be in breach of regulations in relation to people’s safe care and treatment and good governance.

The manager understood their duty to collaborate and work in partnership, so services worked seamlessly for people. However, there were on-going concerns from professionals and partner agencies regarding how this would be sustained without the manager’s input. They expressed a lack of confidence in the provider's ability to maintain the collaborative working established due to gaps in the management structure. Due to these concerns, the local authority felt there was a continued need to have a strong presence and support network from other professionals regularly having input into the service.The provider told us they believed contingency plans were in place for staff who knew people and systems at Heathlands to support the service should the manager not be available.

Partnerships with external professionals and agencies had ensured the service had been supported whilst implementing changes and making improvements. The local authority had met regularly with the manager and provider. The Care Home Support Team, the Safeguarding and Medicines Team had been an ongoing presence and felt their support and advice had been actioned. One professional told us, “We have supported [manager] as a group of professionals. I now have confidence in [manager] that things are now being reported. They respond when you make any recommendations and the frequent complaints from residents and relatives have stopped.”

Links had also been made with the local community. This included several churches in the local area who visited regularly, and contact was made with a nearby school to encourage intergenerational social events. One off events had also been held such as the fire service visiting and meeting with people.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

There were continued regulatory concerns regarding Heathlands Care Centre. This was the fifth inspection of the service since its registration with CQC in 2022. During this time, the service has consistently been in breach of regulations. Whilst improvements have been made at this inspection, ongoing work is required to ensure the remaining concerns are addressed and the improvements made are fully embedded into practice and sustained.

The provider had developed an on-going action plan to embed improvements across the service. However, many of the milestones set for improvement to be made had been missed. These were particularly relevant in aspects care planning and risk management where we identified on-going concerns. No explanation was provided regarding how the milestones were being measured, why they had been missed or what action would be taken to address this.

Where changes and improvements have been made, we found these have had a significant impact on the quality of people’s care. These included changes to the service's culture, staff skills, safeguards against the risk of abuse and unsafe care, communication systems, and staff morale. Feedback from people, relatives, staff and partner agencies in the main credited these changes to the work and attitude of the manager. One relative told us, “Without [manager], I don’t know where we would be.”