Herondale

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 remained 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 service was in breach of legal regulation in relation to good 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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The provider quality improvement strategy did not consistently support the long-term stability or operational sustainability of the service resulting in unclear priorities or a reactive rather than proactive approach to improving. For example, there was not a proactive culture in identifying the concerns highlighted in this report, instead the provider was reactive to our feedback.

Leaders did not consistently model or reinforce the values of the service. We found audits completed by members of the leadership team were not factual or transparent.

The culture was not consistently person-centred. Care plans lacked sufficient detail or had inconsistent information. Without detailed and accurate information, staff were unable to ensure they provided safe care that met people’s needs.

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, and they did not do so with integrity, openness and honesty.

Leaders did not demonstrate that they have the knowledge or capability to provide a safe service. Leaders failed to have effective oversight of risk assessments and care planning documents.

The provider failed to identify where audits were not effective in identifying poor risk mitigation or when audits contained false information. For example, a quality assurance audit completed for 1 person said their care risk assessments were person-centred and enabling. For another person it stated ‘clear and personalised’ plans were in place. This was not factual, we identified significant shortfalls in these care plans and risk assessments, which included, but was not limited to; no mental health risk assessment, no diabetes risk assessment and inconsistent information for monitoring blood sugar levels.

Leaders did not consistently model positive behaviours, including inclusion, openness and co-operation with others. A member of the senior management team had completed a full quality assurance audit of the service on the 19 May 2026.Tthis audit had not been shared with the manager of the service when we visited 3 weeks later. This meant there was not a proactive and supportive approach to enable the manager to make timely improvements based on the feedback.

The manager had been in a permanent role since January 2026. However, they had not yet completed their registration with CQC. The manager showed us their application was ready to submit.

The provider did not always foster a positive culture where people felt they could speak up and their voice would be heard.

People’s social networks outside of the service provider were limited and therefore some people had less opportunity to share concerns external to the provider. When we asked people who they would report concerns to, they did not name the manager. Three people named a long-term member of staff, one of whom said if this person was not around they would wait for their return. Another person told us they did not know the manager’s name. This meant whilst staff were empowered to speak out, individuals who used the service had not been empowered to recognise options open to them.

Staff attended open forums such as team meetings and supervisions where they could raise concerns openly without fear of judgment.

The manager told us they were open to feedback and demonstrated through meeting notes that staff views were considered and listened to.

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 valued diversity in their workforce. However, they did not always take steps to ensure staff were representative of the population of people using the service, for example, there were no male staff members currently employed, so people did not have a choice of gender of staff to provide their care. Additionally, there was no evidence to show people had been consulted with about their preferred gender of staff.
 

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.

The provider did not have effective governance systems in place and failed to identify the significant concerns highlighted within this and the previous assessments.

Roles and responsibilities were sometimes not adhered to. Audits that were titled for the manager to complete were sometimes delegated. This was not a robust or effective approach. For example, medication audits were completed weekly by a member of the management team. There was then a second medicine audit for the manager to complete that included checking the weekly audit. We found these two audits had sometimes been completed by the same person. This meant errors in the weekly audit had not been identified. Additionally, the third tier of medicines audit completed at regional level had not identified the ineffectiveness and poor transparency of these audits.

The systems to assess, monitor and mitigate risks relating to the safety to people had not significantly improved. There continued to be a lack of oversight of the service as the provider and leadership team did not fully monitor and identify where improvements were needed. For example,
risk assessments had not been completed for all known risks related to people using the service. Care plans and risk assessments were not aligned with each other and the diabetes monitoring was not being completed in line with the care plan.

The provider improvement plans were not always effective. For example, a member of the leadership team identified that mental health and physical health monitoring charts should be implemented within the service. We noted this action was repeated on the regional improvement plan for the 6 month period we viewed yet there was no deadline set for the manager to complete this task. Additionally, the manager had not transferred this action to the local service improvement plan. This did not demonstrate accountability.

Whilst we found the provider did report concerns such as safeguarding allegations, we found they did not always effectively investigate incidents or take appropriate action to mitigate risk through lessons learnt. For example, a person had sustained a burn through their own actions. When we asked the manager for the investigation notes. We were informed there was no formal investigation. This meant ways to mitigate the risk had not been considered and the person continued to be at risk. We asked the provider to risk assess and identify ways to mitigate risk to the person.

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.

Care plans did not demonstrate coproduction with other health professionals such as mental health and diabetic nurses.

We emailed external agencies who work with the service and asked for feedback about the provider. We did not receive any feedback in response.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not actively contribute to safe, effective practice and research.

Due to the failings identified at this and the last assessments, leaders were still reactively responding to concerns raised by us rather than being proactive in the development of the service.

CQC assessments completed for the service in 2024 and 2025 found the provider’s internal audit systems were not effective. The provider commissioned an independent audit of the service in 2025 which also found the provider’s audits were not effective. At this assessment we found the provider continued to have ineffective audits and therefore poor oversight of the service. The provider had continuously missed opportunities to learn from feedback about their auditing systems.