Hampshire Head Office Brockhurst Rd

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. This is the first assessment for this newly registered service. This key question has been rated 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 provider was in breach of the legal regulation relating to good governance.

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 did not consistently embed a clear vision or culture based on transparency, equality, inclusion, and human rights. Although some staff and people using the service understood and shared the provider’s values, these were not routinely reflected in practice. Our observations contradicted the provider’s own statement of purpose and stated vision and values.

Restrictive practices (such as inappropriate surveillance and locking away everyday items) had become routine and were not challenged by staff or leaders. These restrictions were not supported by individual risk assessments or legal justification. Leaders failed to promote a culture where autonomy, informed consent, and the least restrictive option were recognised as fundamental principles of care.

Although people told us they felt safe and well cared for, the overall culture did not support full participation or empowerment. Leadership lacked awareness of how cultural norms, such as blanket restrictions, could negatively affect people’s rights and independence. This limited people’s ability to shape their care and live with dignity.

After our visit, the provider showed a willingness to reflect and review policies and restrictive practices. However, stronger leadership and clearer direction are needed to align the service with its values and responsibilities and ensure a shared culture that genuinely promotes human rights, equity, and inclusion.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills and knowledge to lead effectively.

The provider did not consistently fulfil their legal responsibilities. Statutory notifications were not always submitted to the Care Quality Commission (CQC), and when they were, the information was not consistently relevant, accurate, or timely. This hindered external oversight and limited the regulator’s ability to monitor safety and compliance.

The registered manager was open and transparent about areas they felt further development was needed, including their understanding of responsibilities under the Care Quality Commission (Registration) Regulations 2009. However, gaps in leadership capability, such as safeguarding, the Mental Capacity Act 2005, and national guidance including Right support, right care, right culture impacted the effectiveness of governance arrangements.

Systems for identifying and responding to risks, learning from incidents, and monitoring consent and restrictive practices were not yet fully embedded or consistently applied. This meant leaders could not always provide assurance care was being delivered fully in line with national guidance or regulatory standards.

Whilst some aspects of leadership capability did not fully reflect the knowledge or skills needed to meet all regulatory expectations the provider promoted an inclusive and caring culture, which staff spoke about with pride. People and staff told us they felt supported, and we saw evidence of open, respectful relationships throughout the service.

The registered manager showed a clear commitment to building their knowledge. They regularly accessed resources and updates from the Care Quality Commission, the National Institute for Health and Care Excellence (NICE), and Skills for Care. Their engagement with sector guidance showed a willingness to improve and stay informed.

The provider responded positively to feedback and began taking action to strengthen leadership knowledge and oversight. This reflects a commitment to continuous improvement and to building the necessary capacity to meet regulatory expectations over time.

The provider fostered a culture where people, staff, and relatives felt comfortable raising concerns and were confident they would be listened to.

The provider had a whistleblowing policy in place and ensured staff were aware of it. Staff told us they were encouraged to speak up and felt supported by the management team when they did. One staff member said: “I’m the type who will speak up if I have any issues.” They reported feeling empowered to escalate concerns, were confident these would be handled professionally and without fear of reprisal.

The registered manager and team leaders were visible and approachable. Staff described them as accessible and responsive. People using the service told us they knew who to speak to if something was wrong, and they felt listened to. Where complaints had been raised, there was clear evidence the provider responded promptly and resolved them in a fair and appropriate manner.

The provider actively promoted an inclusive culture and took deliberate steps to improve equality and equity across the workforce. Leaders valued diversity and treated staff fairly, creating a positive and supportive working environment.

The provider offered flexible working arrangements to accommodate individual needs, such as health conditions or caring responsibilities. Leaders made reasonable adjustments to support staff in their roles. Staff confirmed they felt respected and included. One staff member told us, “I am treated fairly, and I like it here.”

Managers ensured the staff team reflected the community they served. They regularly engaged with staff through supervisions, meetings and forums, and encouraged open and honest feedback. Staff old us they felt confident raising concerns and trusted leaders to respond appropriately. Staff also completed training in equality, diversity and human rights, which helped embed inclusive values across the service.

The provider did not have effective systems of governance and accountability to ensure the service was consistently safe, person-centred, or well-managed. Governance arrangements were unclear, inconsistently applied, and failed to provide sufficient oversight of key risks and responsibilities. As a result, critical areas of care and support went unchecked, and leaders could not demonstrate they understood or fulfilled their legal obligations.

Systems and processes to manage medicines safely were not effective. Although policies and procedures existed, several contained conflicting guidance or lacked detail. This left staff unclear on how to administer medicines safely and consistently. Practice varied, and this led to medication errors. In one serious incident, a person experienced an overdose that required paramedic intervention. This was reported to the local authority but not to the Care Quality Commission, as required. This demonstrated a failure to follow statutory notification processes and highlighted weak oversight of incident reporting.

Internal audits failed to identify these issues. Auditing systems relied heavily on tick-box approaches and did not accurately reflect the conditions of the service. For example, an audit recorded emergency call bells were in place and functioning, despite no such equipment being installed in people’s homes. Staff had recorded abnormal water and medication storage temperatures in people’s homes during health and safety checks the provider had introduced, but these risks were neither escalated nor addressed. This indicated a lack of meaningful quality assurance and ineffective risk escalation pathways.

Risk management was inadequate. Leaders failed to assess or document environmental safety risks, including the use of CCTV, property access, and the storage of hazardous materials. In one safeguarding incident, an unauthorised person entered the premises and verbally threatened staff. No risk assessment or preventative action followed, despite the seriousness of the event. Restrictions, such as continuous staffing presence, locked rooms, and restricted access to certain items. were applied without evidence of individualised assessment or consideration for the least restrictive approach. These failures reflected a poor understanding of the provider’s responsibilities under relevant legislation, including the Mental Capacity Act.

Oversight of routine operations was also lacking. For example, staff appraisals were not taking place in line with the provider’s own policies, which may have limited opportunities for staff development, performance monitoring, and accountability.

Governance structures were further undermined by a conflict of interest in the provider’s dual role as both landlord and care provider. Roles and responsibilities were not clearly separated, which meant care staff were expected to carry out property-related duties outside their role, such as maintenance and safety checks. This confusion diluted staff accountability and diverted focus from care delivery. Tenancy agreements lacked clarity, and it was unclear whether people understood their rights, including the ability to choose another care provider or restrict access to their homes. These arrangements failed to meet the Real Tenancy Test and posed a risk to people’s autonomy and legal protection.

Although we found no evidence of actual harm at the time of inspection, the cumulative effect of these widespread governance failings placed people at risk of avoidable harm and compromised their rights. Leaders did not act on reliable information about risk, quality, or outcomes. The absence of clear oversight, accountability, and effective systems resulted in a breakdown of the foundations required to deliver safe, responsive, and person-centred care.

The provider recognised their responsibility to collaborate effectively, ensuring services worked seamlessly to meet people’s needs. They actively shared information and learning with partner organisations to drive improvements.

Daily records showed people’s involvement in activities, and photos confirmed staff supported people happily and confidently during outings to the local community.

Staff and leaders maintained strong working relationships with external agencies and stakeholders. Records demonstrate they regularly engaged with the local authority, sought guidance from healthcare professionals, and updated care approaches in response. Staff kept records of feedback and documented meaningful engagement with people using the service and the wider community.

This collaborative approach demonstrated the provider’s clear commitment to coordinated, person-centred care and effective partnership working.

Leaders did not create or embed a culture of continuous learning or innovation across the service.

Systems for quality assurance were not effective enough to identify or act on key service risks. The provider had responded to some past incidents, but learning had not always led to meaningful change.

Areas such as surveillance, restrictive practices, and consent processes continued to reflect outdated approaches that were not person-centred or based on best practice. This showed that learning was reactive rather than proactive.

Despite these issues, the provider had begun to recognise the need for improvement and was open to change. There was potential to embed a stronger culture of innovation and learning with clearer leadership, better oversight, and a commitment to improvement. Sustained action is needed to make sure future learning translates into improved care, safety, and outcomes for people.