Tapton Grove

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 provider was in breach of legal regulation in relation to governance at the service.

This service scored 39 (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 demonstrate a shared vision, strategy or culture that prioritised transparency, equity, equality, human rights, or inclusion. Leaders did not show a strong understanding of the service's specific challenges or the needs of the people they supported.There was no clear evidence that the provider had a well-communicated or embedded vision for high-quality, person-centred care. While some policies were in place, these were not consistently translated into practice. Staff told us they did not feel involved in shaping the direction of the service or that their feedback was meaningfully considered. For example, staff said they raised concerns or ideas but were not always told what had been done in response. One staff said, “Staff are quite demoralised”, another staff said, “Staff are leaving and we use agency, some are good some not so good. We are unsure on the values of the service. We all know things need to improve and quickly”.Leadership approaches were not aligned to the needs of this particular setting. For example, peoplewere able to enter the kitchen, which contained many hazards such as boiling liquids and sharp objects. Whilst this might be acceptable in some other types of services, it was not adequately risk assessed or managed for this specific service user group.Leaders were not consistently visible within the service, and staff described a lack of day-to-day support and oversight. This had an impact on morale and contributed to a disconnect between the leadership team and the workforce.There was limited evidence that leaders effectively engaged with people using the service or sought to understand their lived experience. There was no structured or regular way for people or their families to feed back on the culture or direction of the service, and where concerns had been raised by external stakeholders, there was no clear process for acting on them.There were failings in the application of key principles such as the Mental Capacity Act and Deprivation of Liberty Safeguards, evidencing lack of leadership focus on protecting people’s rights. The lack of oversight in these areas placed people at ongoing risk of receiving care that was not lawful or based on their needs and preferences.This meant there was no strong or cohesive culture driving improvement, inclusion, or accountability within the service.

The provider did not have inclusive leaders at all levels who fully understood the context in which care, treatment, and support were delivered. Leaders did not consistently embody the culture and values of their workforce or the organisation.The service was not always led effectively, which suggested there were gaps in the skills, knowledge, and experience of the leaders.Leaders did not always comply with managing important legal requirements like mental capacity assessments, Deprivation of Liberty Safeguards or submitting statutory notifications, placing people at risk.Despite being aware of serious issues, leaders did not take timely or effective action to address them. This included failing to review and update care plans, manage risks, or follow safeguarding procedures properly.Leaders did not always promote a culture of openness and transparency. For example, there were instances where important incidents were not reported to the appropriate authorities, which meant opportunities to learn and improve may have been missed.Staff did not receive regular supervision or support as expected. This lack of oversight meant staff were not always equipped to provide safe, high-quality care.Staff did not have confidence in leaders. One staff member said, “We can, and do raise concerns (with the leaders) who are approachable and nice but nothing changes”. Another staff said, “We do raise concerns, but very little changes, things are getting slightly better but there is a long way to go yet”. Overall, leadership lacked the commitment needed to create a positive, supportive, and inclusive culture. This affected the quality and safety of care people received

People did not always feel they could speak up and that their voice would be heard.Not all staff felt confident that they would be listened to or that their concerns would be acted upon. While leaders told us they encouraged staff to speak up, some staff said they were unsure what happened after they raised concerns, and whether they led to any improvements.Although there were policies in place to support a culture of openness, some staff told us they feared being treated unfairly if they spoke out. This suggests that staff did not always feel psychologically safe to raise issues or challenge poor practice. One staff said, “we definitely do not feel valued”, another staff said, “They (managers) either don’t listen to us or don’t take actions”. Leaders did not always promote openness and transparency in how they responded to concerns. For example, not all incidents were reported to external bodies when required, and not all staff felt informed about what had been done in response to their feedback.

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.There were no concerns raised in relation to equality, diversity or inclusion within the workforce. Staff did not report any experiences of discrimination, harassment, or unfair treatment based on protected characteristics such as race, gender, sexuality, disability, or religion.Equality and diversity training was provided at induction and refreshed annually. Staff were aware of relevant policies and told us they felt able to raise concerns if needed. We found no evidence of inequitable access to training, supervision, or progression.Some staff told us they did not always feel respected or listened to by leaders; however, these concerns were related to organisational culture and communication, rather than equality or inclusion. The provider had appropriate systems in place to support workforce equality, and staff described a generally fair and inclusive working environment.

The provider did not have clear systems in place to ensure safe, consistent, and well-led care. There were no clear responsibilities or oversight to make sure care was being delivered safely, and risks were not always identified, monitored or acted on.Leaders did not always respond to known risks in a timely or effective way. For example, issues like missing mental capacity assessments, delays in applying for (DoLS), and poor risk management were known but not addressed until after concerns were raised during inspection. This included high-risk cases such as people with a history of carrying weapons, self-neglect, or substance use, where updated risk assessments and safety plans were not in place.The service also failed to monitor basic health and safety risks. People had access to hazardous areas such as kitchens, which contained bleach, boiling liquids and sharp items, without proper supervision or risk assessment. On more than one occasion, food was stored at unsafe temperatures, and fridge checks were not consistently recorded. Staff had raised some of the concerns, but effective action was not taken until after our inspection. Confidential information was left out in shared areas, and safeguarding concerns were not always reported to the relevant bodies. There was no consistent system in place to make sure incidents were reviewed, lessons were learned, or actions followed through.Staff supervision and support were inconsistent, and leaders did not always check that staff were being supported or that people’s care was regularly reviewed.There were significant shortfalls in medicines management, such as the absence of PRN protocols, which increased the risk of unsafe medication practices. Audits of key areas were either not in place or not effective in identifying and addressing important issues, which limited the provider’s ability to maintain safe and quality care.Although an action plan was in place, it did not address all the problems found during inspection, and there was limited evidence that actions were completed or sustained. This showed a lack of ongoing governance and leadership oversight to make sure people received safe, consistent care.

The provider did not consistently engage effectively with external agencies or fully act on their feedback. For example, concerns raised by care commissioners were not always addressed promptly, and issues highlighted by the Integrated Care Board regarding medicines errors were not managed in a timely manner. While the service did maintain communication with local health services, social care, and community organisations, there were occasions when advice and recommendations were not fully followed through in practice.Feedback from people using the service, their families, and community groups was mixed. Some felt involved in-service planning and improvement, while others reported less engagement. There was limited evidence of joint working initiatives or shared learning with partners, and where feedback was received, changes were often delayed or inconsistently implemented.The service did support people to engage with the local community through outings and activities; however, these were not always supported by thorough and up-to-date risk assessments, potentially compromising safety.Overall, the lack of timely and effective response to external feedback and inconsistent collaboration limited opportunities for continuous improvement and strengthened community partnerships

Staff and leaders did not consistently demonstrate the capability to drive and sustain improvement. While some initiatives had been introduced, such as a service-specific action plan, staff-led development of one-page profiles, and a planned leadership programme, these efforts were not yet embedded or having consistent impact. Team meetings were arranged and communicated via the Nourish platform, but engagement was limited, and staff did not consistently feel supported to reflect, problem-solve, or lead on service improvements. Although some staff ideas were encouraged, overall, there was no clear or consistent strategy in place to build staff capability or foster a culture of innovation. This limited progress towards meaningful and sustained improvement