Deep Heart Care Wiltshire

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.

The service was in breach of legal regulation in relation to failing to notify Care Quality Commission of incidents as required by law.

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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

At our last assessment we found leaders were not knowledgeable about providing a good service. We found care records contained language that was not respectful. At this assessment we have seen some improvements. For example, care records had improved, language was respectful and staff were recording in detail the care they were providing. However, further improvement is needed. We also found some entries which were not accurate with regards to missed visits. We shared this with the provider who said they would immediately investigate.

The service did not have a registered manager and whilst there were management arrangements and the provider was very involved; improvement needed had not been made across all areas of the service.

Staff attendance at meetings was low. We checked with the provider why this was, and they explained staff were not paid to attend meetings. Staff did not share any concerns with us about this, however, there was an expectation from the provider that staff would do some elements of their work in their own time.

Staff told us they enjoyed their work and they understood the provider values. One member of staff told us, “I enjoy my role because I like supporting people to remain independent in their own homes and building positive relationships with them. It is rewarding to see the difference we make in people’s daily lives.” This approach demonstrated the staff were understanding of the provider values.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The service had been without a registered manager since July 2025. The provider told us they were actively recruiting a new manager who would be registered but had not found a suitable candidate as yet. Day to day management was being completed by the provider and other managers within the organisation such as the care-coordinator. This approach meant that some supervisions and assessments of competence were being completed by family members on each other within the management structure. This limited opportunities for objective scrutiny and reflective learning.

Staff knew who the management were and felt able to approach them for anything. One member of staff said, “I know the management and they are approachable. They model inclusive behaviour and are supportive when we need guidance or help.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There was a whistleblowing policy and process and staff told us they felt able to raise any concerns. One member of staff said, “I feel able to speak up and my concerns are listened to. I am encouraged to report concerns without fear of blame.”

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 service employed a diverse team of staff and had policies and procedures to help them make sure there was equal opportunities and a welcoming culture. Staff told us they thought the workplace was inclusive and supportive. One member of staff said, “Staff have access to policies and training on equality and diversity. There is support available for staff with different needs including wellbeing support and inclusive workplace practices.”

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.

At our last assessment we found governance systems were not established or effective in identifying improvement and potential risks. Audits being completed were not identifying shortfalls in the service and governance records contained inaccurate information about the service. At this assessment we found improvement had been made and there were various audits being completed regularly. These checks were identifying areas for improvement and actions needed. Some actions were shared with staff in meetings or supervisions.

However, further improvement was needed to the process to make sure the provider had good oversight of all actions identified. It was not always clear what actions had been completed, and which were still ongoing. The provider said they would review their service improvement plan and make sure all actions were added for them to have oversight.

At our assessment in January 2025, we found the provider had failed to notify us of all incidents as required by law. At this assessment the provider has not been able to demonstrate enough improvement, so the service is still in breach of regulation for failing to notify CQC.

The provider had systems for monitoring quality of the service. For example, the provider was completing regular surveys with people. However, the last 2 rounds of surveys had not been collated to produce a summary. Whilst all the feedback was positive, this was not apparent unless each one was read individually. We discussed with the provider that people may wish to receive a summary of the results.

The provider carried out unannounced spot checks of staff to make sure they were following policies and procedures. These were recorded and demonstrated actions had been taken to address any shortfalls in performance.

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.

At our last assessment we scored this quality statement a 1 as there was significant shortfalls. People told us they were not confident staff understood their needs and care records were conflicting and lacked details. At this assessment the score has improved as there has been action taken to address some shortfalls. However, further improvement is needed.

The provider was not clear when to contact the local authority safeguarding team with information. Staff from the local authority had been contacted but not always from the correct teams.

Improvements had been made to the care records, and it was clear which professionals were involved in people’s care. This helped staff to work with others to meet people’s health needs. People did not share any concerns about this quality statement.

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

Since our last inspection the provider had joined a local provider forum and taken steps to join registered manager groups and national organisations for the adult social care sector. However, the provider said they had not been able to join any learning or information sharing events. Whilst the provider has taken steps to make improvements at the service in areas such as care planning, medicines, recruitment and record keeping. Some shortfalls were still identified and had been identified at previous inspections. There was still some reliance on CQC to help identify improvements.

Prior to this assessment, the provider had taken steps to move their checks on quality and safety onto an online system. This helped to give them better oversight of what checks had been completed. The provider was also reviewing other electronic systems they might use to help improve record keeping.