Henwick Grange

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 Inspection we rated this key question good. At this Inspection the rating has changed to require 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 leadership and governance 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 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. Henwick Grange had a vision and targets plan for 2025, topics of this included, people’s wellbeing, improvements for the environment, care development and staff welfare and development. Staff spoke positively about the support they received from the registered and deputy manager and described them as having an “open door” should they wish to share anything. The registered manager was passionate about what they would like to achieve over the coming months and recognised and started to take action where improvements were needed.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always demonstrate the skills, knowledge, experience and credibility to lead effectively. There was evidence of oversight from different leader levels at the service, however, they failed to ensure improvements were being driven. For example, audits were carried out by regional and quality lead staff, but they failed to identify the concerns we found during our inspection. The last quality audit dated June 2025 stated, ‘Does every medicine, tablet, eye drop, cream have opening, and date of expiry recorded on the label’ – this was recorded as ‘yes’. We found no creams to have any open dates recorded on them.Not all audits identified where environmental and infection control improvements were needed. Therefore, we cannot be assured the information recorded in the quality audits were accurate, effective or able to drive the improvements needed at the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People had the opportunity to share their views of the service through regular resident’s meetings. Staff had opportunities to make suggestions and contribute to the development of the service at staff meetings, surveys and through the provider's supervision procedure. There was a comments box in reception for relatives to be able to share information anonymously if they chose to. Staff told us they felt able to raise concerns and these would be listened to and acted upon. The registered manager understood their responsibilities under the duty of candour. The duty of candour is to be open and transparent, and it sets out specific guideline's providers must follow if things go wrong with care and treatment. The provider had a whistleblowing policy in place.

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. The service promoted an inclusive and fair culture, and all staff we spoke with told us they were treated equally and were happy to work as a team. One staff member told us,” We care, we look after and protect our residents, we are like a family”. Staff told us there was good teamwork at the service and staff worked well together and helped each other. Staff had received training in equality and diversity.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. Although multiple service audits had been completed these were ineffective as they had not identified the issues we found during the inspection. Environmental and infection control audits had been completed which had failed to identify safety risks posed to people. Infection control audits had not identified where parts of the building were unclean. This put people at increased risk of harm. There were a number of gaps in people’s daily care logs and some parts of care plans required additional detail, for example with bowel monitoring and end of life choices. The providers governance systems had not identified this, therefore we could not be assured actions had been taken. The service had gathered feedback from people in relation to improvements they would like in respect of dignity and choices. Whilst action had been taken at the time, management oversight did not ensure this was put into daily practice and we observed not all staff were following this during our inspection. The provider was very receptive to our feedback and started taking action to address some of the concerns we raised.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information with partners and collaborated for improvement. The registered manager told us they had been working with the local police team and had arranged for an officer to visit people at the home to discuss how people could protect themselves from the risk of fraud. The registered manager said they received support from the provider and quality and clinical leads should they need support or advice with a concern.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe and effective practice. Some areas of improvement had not been identified through the management checks, audits or processes. Additionally, when concerns had been identified, actions were not always taken. These audits were not always effective in highlighting shortfalls and driving improvements at the service. Although improvements had been made during our inspection visits, further improvement was needed to ensure the service had embedded a robust governance system which identifies shortfalls of safe care delivery and treatment.