The Royd

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 did not always identify or act on known concerns in a timely way, such as taking action relating to fire safety and the environment, putting people who use the service at risk.

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

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 did not consistently demonstrate a clear and shared vision or strategy that supported timely action and strong leadership.

While managers and staff promoted an inclusive and supportive culture within the service, the provider did not always respond promptly to concerns raised by managers. This meant the overall direction and engagement were not fully aligned across all levels, evidencing a lack of shared direction and responsiveness at senior leadership level.

However, staff and managers were passionate about making a difference for people and described strong teamwork and mutual support. One staff member said, “Managers are supportive with any issues or problems… whatever you need they are there.” A manager told us, “We have a good relationship with all the team… we are happy, diverse and work together.” Staff described an “open door” culture where they felt confident to approach managers. Newer staff said they felt well supported and encouraged to develop their skills. There was a clear focus on learning and improvement within the service, and staff demonstrated a commitment to achieving positive outcomes for people.

The provider did not always respond promptly to concerns raised by the service, which meant leadership support was not consistently effective across all levels.

Although managers felt they could access support from the provider, concerns raised by the service were not always acted on in a timely way. The lack of responsiveness meant provider-level leadership did not consistently ensure safe and effective care. Staff also told us there had been some changes at provider level, which sometimes affected continuity and clarity of direction.

Despite these issues, managers at the service were capable, compassionate, and inclusive. Managers understood their responsibilities and kept up to date with regulatory requirements. They led by example, encouraged teamwork, and created a positive environment where staff felt respected and valued. One staff member said, “Managers are very supportive, I will always speak to them.” A manager told us, “We have a good relationship with all the team. It’s a happy environment, and if the atmosphere isn’t right, I know it.”

The provider fostered a positive culture where staff and people felt confident to speak up and believed their concerns would be listened to and acted upon.

Staff and managers described an open and supportive environment where they could raise concerns without fear. One staff member told us, “I feel I could raise concerns if needed. I’m quite fond of the management – they’re really lovely.” Managers acted with openness and honesty and encouraged constructive challenge. When issues were raised, managers investigated sensitively and confidentially, and lessons learned were shared through handovers and meetings. Staff gave examples of reflective practice and teamwork and how problems were resolved quickly. Staff demonstrated pride in their work and commitment to collaboration. One person said, “If only half the team puts in effort, there will be no progress. Everyone should work together and give 100%.” This showed a strong sense of accountability and shared responsibility. The provider also sought feedback through a national employee satisfaction survey, which highlighted areas for improvement such as pay, training, and workload. In response, the provider set out plans to strengthen career development, improve onboarding for managers, and enhanced wellbeing support. These actions demonstrated a commitment to listening and acting on staff feedback.

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.

Staff told us they felt respected and treated fairly. They said they were happy working for the provider and felt confident their voices were heard. One staff member told us they felt supported and able to raise any concerns. Managers were regularly available through supervision and team meetings, giving staff opportunities to share views and engage in decision-making. Staff described the workplace as diverse and inclusive, with people from different backgrounds working well together. One person said, “We blend – there are no differences between people.” Staff told us everyone was treated as equals and had equal opportunities. Staff also said they were committed to providing care without discrimination, focusing on meeting individual needs. There were procedures in place to consider individual requirements and ensure staff were treated equitably. Helping foster a positive and supportive culture. Staff spoke about feeling listened to, valued and described the environment as having a “really good culture” where diversity was respected.

The provider did not have clear responsibilities, roles, systems of accountability, or effective governance arrangements. They did not act on the best information about risk, performance, and outcomes, and failed to take timely action to address known hazards.

Governance systems and processes were ineffective in identifying and acting on risks. Environmental hazards and fire safety concerns had been highlighted through audits and risk assessments, yet many actions remained outstanding for long periods. For example, some remedial works on fire doors identified in July 2024 were still incomplete at the time of inspection, despite being recorded on the provider’s systems. Immediate action was only taken after the inspector raised urgent concerns. Upon reviewing the provider’s organisational audit, dated 14/04/2025, it was evident that the provider was aware that the outstanding actions on their systems related to fire risk assessment actions. Through observation, it was clear that action was still required. From discussions with leaders, it was identified that there was a process problem.

Environmental checks had not prevented significant deterioration, and several areas of the service were in poor condition. The kitchen, bedrooms, bathrooms and communal areas all showed signs of wear and damage, including issues that compromised safety such as loose door handles on the COSHH cupboard. The general standard of maintenance did not support a safe, clean or well‑maintained environment. Waste management processes were ineffective. Despite requests from the management team weeks after collection was requested. Window safety checks were not robust. Some upstairs bedroom windows and stairwell windows lacked restrictors, leaving people at risk of falls from height. Infection prevention and control (IPC) checks were carried out by managers which identified issues such as the need to replace kitchen worktops, however these were not effective in driving timely action, leaving hazards unresolved.

Systems for monitoring incidents were in place but not always used effectively. For example, one safeguarding incident was not notified to CQC until inspectors raised the issue. Daily log audits were found to not always be consistent with the care being provided. Trends and themes from incidents were not clearly documented or analysed to prevent recurrence.

Following the inspection a building refurbishment plan has been added back on the provider’s agenda. The service is keen to learn and implement measures to prevent such lapses in oversight from happening again.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff and managers engaged with people and external agencies to share learning and identify ways to improve care. Training and support from mental health services helped staff develop skills and confidence, and the Provider’s regional Quality Team provided reflective practice sessions to strengthen care delivery. Staff and managers demonstrated a clear understanding of the importance of partnership working. They collaborated with external professionals, including mental health teams, social workers, and the GP, to ensure people received the right support. Staff told us they had good relationships with healthcare professionals and could access advice when needed. One staff member said, “If we need support, they are on hand.” People and relatives told us that access to appropriate health professionals was arranged when needed. Staff supported people to attend healthcare appointments and had access to contact details for relevant professionals within people’s support plans. They made referrals when appropriate and ensured people had the right support in place when further conversations took place with other healthcare teams. While formal evidence of partnership working was limited, staff demonstrated a strong understanding of their role in supporting people’s health and wellbeing through collaborative working.

The provider focused on continuous learning, innovation, and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome, and quality of life for people and acted on feedback to improve services.

Leaders and managers promoted a culture of learning and improvement. Staff told us they were encouraged to share ideas, with one staff member saying, “Managers genuinely welcome feedback, even if it’s critical.” Managers demonstrated how feedback had led to changes, such as simplifying the sign‑in process for their care planning system in collaboration with IT teams. Staff worked together to manage the transition from paper to digital records, with training provided for those less confident, and managers celebrating their progress. Technical concerns were raised and escalated appropriately, and managers kept staff updated on planned improvements. There were clear processes for learning when things went wrong. Lessons learned from incidents were documented and shared through meetings and handovers, and leaders encouraged reflective practice and problem‑solving. Although systems were in place for staff and people to share suggestions, these were not always used.

Following concerns identified during inspection, the provider introduced a Compliance Committee to strengthen oversight of safety and regulatory requirements. The committee included senior leaders and focused on rapid escalation of risks, such as maintenance issues and fire safety checks. A new Quality Improvement Plan was implemented, with actions tracked through the provider’s internal systems to ensure accountability. The provider demonstrated commitment to improvement by acting promptly on feedback and introducing measures to maintain compliance and safety.