Harper house - Wolverhampton

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• 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 is the first assessment for the service under this provider. This key question has been rated 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 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a poor culture at the service that did not promote or empower staff to provide safe and effective care. The provider’s vision for the service was not always met.

The majority of staff we spoke with described a poor culture at the service. One staff member said, “Yes there is a culture between staff and the managers. They shut us down. We don’t see [provider] much to be honest”. Another staff member told us they felt the management team didn’t care about safety or quality at the service. They said they, “Didn’t listen when we raised concerns to [management team], they didn’t care.”

The provider told us, “Service users come first to ensure they are safe” and, “We ensure we improve their quality of life.” However, we found this vision for the service was not always met. As described under our safe key question, people did not always receive safe care and assessments and reviews had not identified that some people were unhappy living at the service.

Despite the poor culture described by staff, staff did describe wanting to make a difference for people.

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.

Staff gave mixed feedback about the management team. Comments included, “They are not good at leading,” “Current managers don’t support us now” and, “I think the managers could be better.” However, some staff spoke more positively about the managers, saying, “[Manager] will call us to order if there is a problem” and, “[Manager] is doing a good job for the home and service users.”

There had been no CQC registered manager at the service since August 2025. At the time of our inspection, the manager at the service had applied to register with us. However, they withdrew their application immediately after our inspection. This meant there had been no legally responsible individual managing the service for a period of 10 months leading up to our inspection.

The management team had not identified the concerns we have reported on throughout this report which showed they did not have the skills, knowledge and experience required to ensure safe and effective care was consistently provided to people.

Some staff also described the management team as dismissive and unsupportive at times and we heard from staff there had been missed opportunities to act on some of the concerns we have reported on. For example, as reported on under treating people as individuals under our caring key question, a staff member told us they had raised a concern about a person not getting food choices in line with their cultural and personal preferences. However, their concerns had not been listened to or acted upon.

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

Some staff described feeling they could not always confidently speak out about care concerns. Comments included, “We’ve been told not to go to [provider] as it is going above the heads of [management team]. I feel bullied, I feel disheartened, I feel deflated, I feel I haven’t got a voice.”

“We were told not to go to [provider]” and, “I wanted to put a grievance in, but I didn’t want to face repercussions.” However, some staff did tell us they felt able to raise a concern to the management team and/or the provider.

Although the provider had a whistleblowing policy in place, as staff did not consistently feel they were able to speak up, there was a risk of a closed culture at the service. A closed culture is described as, 'a poor culture that can lead to harm, including human rights breaches such as abuse'. In these services, people are more likely to be at risk of deliberate or unintentional harm.

The provider could not always evidence that they valued diversity in their workforce.

The provider told us there were procedures in place to consider staff’s individual needs, which included considering staff’s diverse needs and treating all staff fairly and equitably. However, we did not see any evidence of these procedures in practice and some staff described being treated in a manner that they believed was unfair. For example, 1 staff member told us they had approached the manager and requested to be upskilled to enable them to complete safeguarding referrals independently. However, they informed us this request had not been listened to or actioned to support their development.

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, or share this securely with others when appropriate.

Governance systems had not identified and addressed the safety and quality concerns we have reported on throughout this report. For example, managers and the provider had not identified people were receiving unsafe diets, placing them at increased risk of choking. Systems in place to assess and monitor the safety of the environment had not identified or addressed the environmental risks such as the risk of scalding we have reported on under safe environments. Not operating effective governance systems placed people at significant risk of preventable harm.

The provider did not always work effectively in partnership, so services worked seamlessly for people.

Advice and recommendations from professionals including speech and language therapists and the fire service was not consistently followed or promptly acted on to promote safe and effective care and a safe environment.

The local authority informed us that the provider’s relationship with them was negatively impacted immediately after the inspection process.

However, care records showed examples where staff at the service engaged positively with visiting health and social care professionals.

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

Effective systems were not in place to ensure consistent learning from all incidents that occurred. This meant there were some missed opportunities to learn from incidents and improve people’s care experiences.

Immediately after our inspection, we requested an action plan from the provider to address the high level risks reported on under our safe key question. This included assurances around choking and environmental risks. The provider submitted an action plan as requested. However, this did not effectively address all the issues to ensure prompt and effective action was taken to mitigate all high level risks. We therefore urgently imposed conditions onto the provider’s registration, in order to safeguard people. We were unable to assess the provider’s compliance with these conditions as the local authority supported all people to move out of the service following our inspection.

However, throughout our inspection, the provider was responsive to our feedback and information requests. There was also evidence to demonstrate the provider had significantly invested in renovating the service, aiming to improve the home environment.