Heart of Gold Homecare Ltd

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 requires improvement. At this assessment the rating has remained the same. 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 provider breached regulations in relation to governance. Although the provider had governance systems and processes in place, they were not robust. There was a lack of evidence of regular audits taking place and those which were shown were not robust and did not feed into the continuous improvement plans. Other systems and processes for reviewing policies and mandatory training needed to be operated more effectively to ensure compliance.The provider also needed to ensure there were robust review arrangements of people’s complex needs (e.g. PEG care) via ongoing clinical review in collaboration with external healthcare professionals. Review arrangements including frequency, roles and responsibilities needed clearly identifying.

This service scored 57 (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 had a set of values and a mission they wanted to achieve but this was not always the case. However, the provider ensured there was a good culture within the staff team.

The provider had 6 values which were compassion, respect, excellence, partnership, teamwork and inclusivity. The service user welcome guide stated the values were respect, dignity, compassion, trust and excellence which meant it had not been updated. The values were not always being met, for example we did not find the service was working well in partnership with others.

The provider’s mission included wanting to empower every person they supported to live independently, safely, and with dignity in the comfort of their own home and committing to delivering a first-class home care service that promoted choice, wellbeing, and personal autonomy. However, a lack of robust processes did not support staff to ensure the mission was achieved.

Staff were complimentary about the registered manager and felt there was a good culture in which they could speak up openly without fear of detriment.

The provider’s team meeting minutes demonstrated praise for staff’s hard work and increased workload due to winter pressures.

People and relatives told us they felt the manager was approachable. A relative said, “At the beginning, I had daily contact with the manager but recently now everything is running smoothly I only speak to the manager if I need to. It is nice to know they are there if I need.”

Leaders did not fully understand the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge and experience to lead effectively.

The registered manager, when asked about the key risks and issues for the service currently, did not identify the issues found on the inspection.

The registered manager had been in post for 3 years. They had qualifications in management and told us they had regular contact with another registered manager who was experienced in their role. They did not have the ‘train the trainer’ skills required to be completing competency checks on staff for specialised personal care, as mentioned under the safe and effective staffing quality statement. Their knowledge regarding what constituted safeguarding concerns needed strengthening, as mentioned under the safeguarding quality statement.

The registered manager did not have effective insight about the issues and priorities for the service, and risks were not always professionally managed. However, they acted to address cultural issues in a timely manner and were visible within the service.

The registered manager was responsible for most of the tasks within the service; this included audits, action plans, liaising with partners, the finance and managing complaints and incidents. Given the shortfalls identified during the inspection, the registered manager would have benefited from delegating some of the tasks to responsible and experienced staff members.

Staff were complimentary about the registered manager’s skills and experience and competence in their role.

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

Despite concerns being raised to CQC about staff’s concerns regarding speaking up at fear of detriment, we found quite the opposite. All staff we spoke with confirmed they were able to raise concerns in confidence which would be reviewed by the registered manager.

The provider had information which was visible to staff at the main office which contained details of how they could raise concerns, including contacting the CQC or a whistleblowing advice line.

The provider had the appropriate policies and procedures available for staff to speak up.

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 provider had an equality, diversity and inclusion policy which reflected the latest legislation and best practice.

Staff had completed enhanced equality, diversity and inclusion training as part of their core induction and annual refresher programme.

Staff told us they were treated equally by the registered manager. They said the registered manager was flexible in their approach.

Staff told us they had been promoted into different positions, and these had been based on performance and merit.

Staff had opportunities to speak up about concerns they had about inclusion or workplace culture.

The registered manager told us they marked key cultural and awareness events throughout the year—such as Black History Month, Eid, Diwali, Pride Month, and International Women’s Day—to recognise the diversity within the team and foster inclusion.

Although the recruitment process was designed to ensure fairness and remove bias via structured interviews, and clear scoring frameworks, we found the interviews were being completed solely by the registered manager which created risks around bias and a lack of transparency.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The providers audits had not identified the areas of concern which had been identified during the inspection. Despite requesting a copy of the provider’s last 3 months of audits, we did not receive all of them. The provider demonstrated some audits were taking place, but these were mainly out of date or were a description of findings, as opposed to audits. For that reason, we were not assured all audits were taking place in line with the providers quality and quality assurance and auditing policies. The audit schedule did not identify all the audits which should have been completed, in line with the providers policies.

Systems or processes were not always robust, leading to poor oversight of some areas. The registered manager did not have effective oversight of staff’s training compliance and how many modules staff were completing in a single day, the training requirements for themselves to ensure they were deemed as being competent or safeguarding concerns. There was evidence of schedules for processes such as spot checks, supervision and competency assessments but these were not always completed in line with the plans.

The provider needed to improve to ensure the data about the service was up to date. During the planning phase of this inspection, we identified the provider had an incorrect statement of purpose and the registered manager had not updated their personal contact details with us. We raised this with the registered manager on the first day of the inspection and over a month later these documents had not been submitted.

The registered manager had a good knowledge about what data they needed to submit to CQC including statutory notifications, but we did not receive these in relation to the 2 safeguarding incidents which had been identified by the local pharmacy team and during the inspection.

The provider had a business continuity plan in place to ensure the safe and effective delivery of care in the event of emergencies or unforeseen disruptions.

The registered manager acted when there were disciplinary matters to be managed.

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 provider was not always collaborative and cooperative with external partners. One partners experience had not been positive and they outlined difficulties accessing information in a timely manner.

There was limited evidence of the provider working with other organisations. The registered manager needed to develop networks with communities and partners.

The provider supported people to access the community. There were diary entries in which staff had supported people to access leisure activities and social gatherings.

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 registered manager’s ways of identifying and implementing improvement were inconsistent. We saw a variety of continuous improvement plans which covered a wide array of areas. The plans varied in their style and quality, although overall were detailed. However, we were unsure where the detail, such as the concerns, had been identified from. Frequently, continuous improvement plans, or action plans had identified issues following regular audits but as already mentioned this was not robust. Similarly, further data, which was being collected, was not being analysed to its fullest to identify themes to drive improvements. For example, the provider was collecting rich data from people regularly and would respond to them if there were concerns but there was no thematic review of responses being completed.

The provider’s actions to make improvements tended to be reactive. In 2023, the CQC completed an inspection of the service and found there to be issues with the staff recruitment files, medication management and their governance systems and processes. Since this inspection, the provider had made improvements to medication management and were no longer in breach of regulation. However, in 2025, concerns were raised to the CQC from whistleblowers about the provider regarding some of the issues identified at the last inspection. Although some progress had been made there were still areas which needed to be improved including good governance.

The provider sent an improvement plan which we assumed was their overarching quality improvement plan for the service. Instead, this was a quality improvement plan which had been formulated in February following a visit from an external professional who had completed a mock inspection. Some of the actions, despite their proposed date of completion being in February were ‘in progress.’ The management of staff recruitment files was deemed to have been completed in March 2025, but issues were identified by the local authority following this which means the actions were not completed appropriately.