The Terrace

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

This service scored 54 (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 values and a vision in place, but these were not consistently promoted or embedded in practice. They did not always demonstrate a clear shared strategy or culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The provider had not effectively engaged with people, staff and relatives. Staff told us they were keen to improve the service but did not feel they were encouraged to do so or listened to. One staff member told us, “We should know more about the service users and what’s going on. [Management] should tell us if there is a problem so we can help.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge and experience to lead effectively.

The service had experienced a period of instability within the management team, which had impacted continuity of leadership and oversight. At the time of the inspection, there was no deputy manager in position and the registered manager had made the decision to step down from their role. Arrangements for interim management and longer-term succession were in progress and these positions had since been filled. Leaders acknowledged the challenges this had presented on staff morale. Staff told us they were aware of the changes and described some uncertainty during this period. However, not all family members had been made aware.

Staff told us leaders did not always recognise and address the challenges they experienced and did not take action to address issues raised.

People did not always feel they could speak up and that their voice would be heard.

The provider had a whistleblowing policy and systems in place for staff to raise concerns. However; staff told us they didn’t feel they would be listened to and several staff told us how they had raised concerns that they felt were not acted upon.One staff member said “I wouldn’t know who to escalate concerns to, I have no confidence in the manager to deal with issues. No faith in management side of it.”

The provider valued diversity in their workforce and had up-to-date equality, diversity, and human rights policies in place. Staff had completed the relevant mandatory training.

Staff told us how they had been supported to work flexibly to fit around the caring commitments outside of work. However, employees reported feeling undervalued, citing a lack of engagement and poor communication from management.

The provider’s systems for oversight and accountability were not always effective, and some processes did not consistently evidence safe or effective care. They did not always act on the best information about risk, performance and outcomes.

Oversight and analysis of clinical risks and outcomes was not always accurate, meaningful or up to date. Information and data gathered from systems was not always used to identify areas of concern and drive improvement. For example, reports on call bells were produced but no analysis was completed by the manager to improve outcomes for people. People were waiting long periods of time for call bells to be answered. People, relatives and staff also raised this as a concern.

Audits were not effective in improving the quality of care received and actions had not always been completed. Accidents and incident were not effectively monitored resulting in appropriate action not being taken. The registered manager did not always attend meetings in line with the provider’s expectations. We could not be assured they had effective oversight of clinical risks within the service.

There were on-going issues and concerns raised around the quality of food provided. Meal-time experience audits had been carried out but these had not addressed the issues identified by people, relatives and staff.

Following a local authority visit to the service the provider implemented a quality improvement plan to support the service. However, staff were not clear what this was or the issues to be addressed as part of this.

The provider understood their duty to collaborate and work in partnership to benefit the people they supported. They shared information and learning with partners and collaborated for improvement.

The management team and staff were open and honest throughout the assessment. The service worked with external professionals when required. The service was working with the local authority improvement team to address issues both prior to the assessment and following feedback from our assessment.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Service improvement plans had been implemented at the end of March 2026. Actions were noted as completed and closed in April 2026 in areas such as medicines, however numerous concerns were identified with medication management as part of this assessment.

Staff and relatives did not feel they were actively involved in the development of the service. Recent changes within the management team had further impacted the relationship between staff and leaders. The provider had taken steps to address this and felt the current changes in leadership will bring about positive change.