East Hampshire DCA

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 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 service was in breach of legal regulation in relation to good governance.

This service scored 61 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff demonstrated values such as respect, compassion and integrity, which aligned with the provider’s stated aims. Staff spoke positively about the culture within the service, including approaches such as active support and involvement in meetings, and we observed these values reflected in interactions with people.

Leaders did not always demonstrate the level of capability required to maintain effective oversight of the service. They did not consistently recognise risks or shortfalls in practice, which meant some concerns were only identified during inspection rather than through leadership monitoring. This showed that leaders did not yet provide reliable assurance across all areas of the service.

Despite these gaps, leaders promoted a supportive and inclusive culture. Staff consistently spoke positively about the registered manager, describing her as approachable, visible and respectful. They told us, “She’s a manager that listens, you can walk up to her at any time.” The registered manager demonstrated compassion and inclusivity in her approach and was suitably qualified and experienced. She also reported feeling supported by senior leaders through supervision and peer networks.

Although leaders responded openly and constructively when concerns were raised, they did not always identify issues proactively. This meant while leaders were compassionate and inclusive, they were not consistently providing the level of oversight needed to sustain improvement.

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

The provider had a whistleblowing policy in place and posters were displayed on the wall. Staff knew how to raise concerns. One staff member told us, “However you are feeling or whatever grievances you have, raise it to the appropriate people, there is always someone available”. This reflects a positive and open culture among the staff team.

A person living at the service told us they would speak to the manager if they weren’t happy and if the manager wasn’t available, they detailed a number of other staff they would speak to.

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.

Leaders demonstrated a commitment to equality, diversity and inclusion, ensuring that staff were supported to carry out their roles safely and effectively.

Reasonable adjustments were in place for staff with identified accessibility needs, including the provision of tools to assist individuals who require support with reading printed information. The manager told us flexible rota arrangements were available to accommodate staff with recognised personal or caring responsibilities. These measures help ensure all staff can participate fully in the workforce and feel valued within their roles.

The provider did not demonstrate effective governance arrangements. They did not always act on the best information about risk, performance and outcomes.

Although the registered manager had identified areas for improvement and was keen to implement positive changes, not all concerns found during this inspection had been recognised through the service’s own quality assurance processes. This included risks to people, and non-compliance with the Mental Capacity Act (MCA). In addition, unmanaged environmental hazards, outdated and inaccurate risk assessments, weaknesses in medicines governance, and care records that did not evidence delivery of agreed funded support or demonstrate outcomes had not been identified through internal oversight.

Actions listed on the service action plan were not always completed within the identified timescales, and there were no progress notes or explanations for delays. For example, Mental Capacity Act assessments and best‑interest decisions were recorded as only 50% complete despite a target date of 30 August 2024, with no clear rationale as to why this remained outstanding after 18 months. Target dates and completion dates were not always evident and while the action plan set out required tasks, it was not clear how this was being used to effectively drive or evidence improvements in quality.

Despite these gaps, the registered manager was receptive to feedback and responded positively throughout the inspection.

The provider understood their duty to collaborate and work in partnership. They shared information and learning with partners and collaborated with them. The provider and staff worked with a wide range of relevant external stakeholders to support the provision of people’s care including local authorities, learning disability nurses and GP practices.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

The service action plan was not routinely updated or reviewed in a way that demonstrated progress, and key areas of learning were not clearly tracked through to completion. Some actions remained only partially addressed over extended periods, and the absence of clear updates made it difficult to understand what had been achieved or how learning had influenced service development. As a result, the provider could not show how identified learning translated into meaningful improvements or sustained changes in practice.

The registered manager was open to feedback and responded positively during the inspection, but learning was not yet applied in a reliable or sustained way.

The provider had elements of a learning culture, but these were not embedded well enough to demonstrate learning consistently informed service development or improved the quality of care.