Cleadon Court

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 was the first inspection for this 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.

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.

A clear shared vision and culture had not been consistently understood or embedded across the service. Over the last year there had been significant concerns regarding leadership, management stability and oversight. Professionals and relatives consistently report frequent changes in management, reliance on interim arrangements, and lack of consistent leadership presence. This has contributed to confusion, poor task ownership, delays in follow‑up and anxiety for people supported and their relatives. While leaders described an intention to deliver person-centred and inclusive care, this was not always reflected in practice. Staff understanding of the service’s values and priorities was variable, and some were unclear about how these translated into their day-to-day roles. This inconsistency meant the culture was not always cohesive, and people’s experiences were not reliably shaped by a shared direction. Leaders had started to recognise these gaps and had begun to communicate expectations more clearly, but this work was at an early stage and had not yet led to sustained improvement.

The deputy manager and team leaders were visible within the service and staff described them as approachable. However, leadership oversight and consistency were not always effective. Since July 2025 no registered manager had been in post. Managers had been appointed but left prior to applying to be registered managers. On 7 April 2026 a new manager came into post, and they had commenced working to make improvements. While leaders demonstrated commitment to improvement, this needed to be translated into timely action or inclusive decision-making. There was limited evidence that leaders consistently used feedback from staff and people to shape improvements. As a result, leadership did not yet fully promote a compassionate, inclusive and empowering culture across the service. A visiting professional said, “Often when senior management is in place due to issues/managers leaving, it feels a little like putting a plaster over the cracks until another manager is sourced. This has led to confusion amongst the staff as they have no strong and consistent leadership.”

The new management team fostered a positive culture where people felt they could speak up and their voice would be heard. People, and staff told us they felt confident to raise concerns with the management teams and these would be listened to and acted upon. Staff felt their views and suggestions were actively taken on board. A staff member said, “We do have staff meetings on a regular basis where issues are raised and suggestions to resolve them are raised and best of the suggestions are taken to solve the situation.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. The provider valued diversity and ensured they followed best practice guidance.

Governance systems were in place, but they had not always been effective in identifying risks or driving timely improvement. Audits and monitoring activities did not consistently result in clear action plans or sustained change. Leaders had not always able to demonstrate how oversight systems assured the quality and safety of care. This meant that some issues had persisted without sufficient challenge or escalation. The new management team understood the areas requiring improvement and were in the process of putting measures in place to support long-term sustainability and assurance.

Staff understood and carried out their duty to collaborate and work in partnership, and services. Professionals generally described engagement with the service as cooperative. However, partnership working was largely reactive, and there was limited evidence of shared strategic planning or joint learning. While partnerships supported people’s immediate needs, there were opportunities to strengthen collaboration to further improve outcomes and service development. A professional said, “We carried out a visit in November 2025, which highlighted significant concerns in relation to leadership and management oversight, accuracy and quality of care planning, person‑centred approaches and gaps in specialist training. The provider has been completing an action plan, and although progress has been made, several actions still require further attention to ensure consistent and sustained improvement. However, the service has remained engaged throughout the process, has been receptive to feedback and we have observed a genuine commitment from the team to implement changes and improve the quality of care.”

The provider had processes in place to learn from incidents, feedback and complaints. However, within the service learning was not always clearly analysed or shared to drive improvement. The actions staff had taken to make improvements were sometimes short-term and did not consistently lead to sustained change. There was limited evidence of innovation or systematic evaluation of improvement initiatives. The new management team acknowledged the need to strengthen learning systems, but these were not yet embedded in a way that supported continuous improvement.