Heartlands

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

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good

This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

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.

The registered manager told us about their values which included ensuring people’s needs were met safely, staff were well trained to do their jobs, to be open honest and approachable to people and their families, and to ensure everyone has a good quality of life.

The registered manager demonstrated clear awareness of the provider’s values. The majority of staff we spoke with were positive about working at the service and felt well supported in their roles. However, 2 staff said if there was a problem they would not feel comfortable to raise concerns with the management team. Other staff found the new registered manager supportive and were not afraid to respond to emerging issues. One staff member said the new manager had made positive steps to deal with previous issues and where staff practice needed to be addressed, the manager was actively involved.

Regular staff meetings took place, and we saw minutes of these. The minutes showed that the meetings were used as an opportunity to keep staff informed of expected standards and an opportunity for staff to raise any concerns. Daily flash meetings took place and were attended by the management team. Some staff told us morale amongst staff was “good” and that they enjoyed their roles.

Staff surveys had been carried out and the latest results showed staff satisfaction levels had started to improve.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The provider had recently appointed a new manager who they told us they had submitted their application to become registered with us, CQC. The new manager had previously been a registered manager at another care provider run by the same company and knew the provider’s systems and process well. They had already identified and prioritised improvements that needed to be made and demonstrated a commitment to improving standards within the home.

Staff told us the management team were visible and accessible. The majority of staff spoke positively about the new manager.One staff member told us “The registered manager walks around, if needed she will get stuck in. We have an incident where a resident was unsettled, and she came up to stay with them and help.” Another staff member said they had found the new manager, to be “very approachable, supportive and helpful” and the deputy to be “very good.”

Relatives spoke positively about the new manager who they found approachable and responsive to their concerns or needs. One relative told us, “It’s going along quite well in terms of the new manager. The place is run like clockwork. The manager doesn’t isolate herself in the office but goes around.” Another relative said “[The service is] 10 out of 10 I couldn’t ask for more. It’s a good place and managed properly. I have seen them [staff] work well together.”

The registered manager informed us that a new initiative called “Drop-in Wednesdays” had been introduced. This weekly session offered an informal coffee and chat opportunity, designed to make it easier for relatives, people using the service, and staff to meet with the manager. The aim was to provide a friendly and open environment where concerns, suggestions, and feedback could be shared freely.

As this initiative was still in its early stages, it was too soon to fully assess its impact. However, it was expected to contribute positively to building stronger relationships and support mechanisms within the service.

People did not always feel they could speak up and that their voice would be heard.Staff told us they were aware of the provider’s whistleblowing policy and majority of staff felt confident to speak up if they had concerns about poor care.

Some staff members told us they felt able to raise concerns with the manager at any time. However, 3 staff members shared their personal experiences of bullying and racial harassment from visitors to the service. These concerns had been reported to the registered manager, and while some measures were implemented to support the staff, they felt that not enough action had been taken to address all issues.

This matter was escalated to the management team, who were aware of some of the concerns raised with us. However, they advised that they had not previously been informed of the racial harassment concerns. Once this was raised with the on-site management team which included the registered manager, deputy manager, area manager, and operations manager they acted immediately and spoke with the affected staff and gave strong assurances that any form of racial harassment or bullying would not be tolerated within the service.

As a direct result of staff speaking up, further work was initiated by the management team to ensure that staff are fully supported going forward. This includes highlighting clear anti-bullying and anti-harassment protocols, to staff with access to confidential reporting channels, delivering refresher equality and diversity training for all staff. Introducing regular monitoring to ensure that concerns are addressed promptly and effectively. The management team also committed to reviewing visitor policies to reinforce expectations around respectful behaviour and to escalate any breaches immediately.

People and their relatives we spoke with felt they could raise concerns freely. For example, a relative said “You can knock on the manager’s door at any time and have a word. It’s well managed as staff are always there to support.” Another relative said, “They [management] are welcoming and there’s no rudeness. They prioritise the residents and work well together.”

Feedback was actively encouraged and acted upon. After relatives’ meetings, the service shared a ‘You said, We did’ summary, so families could see how their suggestions had been listened to and addressed.

Complaints and concerns were logged and investigated. The registered manager followed the duty of candour principles when dealing with complaints. The registered manager was open about some of the concerns leading up to this inspection and told us they felt confident a thorough investigation had been carried out and process followed.

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 provider demonstrated a commitment to promoting equality, diversity, and inclusion (EDI) within the workforce. Systems, processes, and training were in place to support these values, contributing to a respectful and collaborative working environment. Three members of staff reported concerns to us regarding racial harassment by a visitor to the service. We brought this to the attention of the management team who took immediate steps to investigate and address these concerns, supporting the affected staff. The provider responded by reaffirming their commitment to the safety and wellbeing of care staff. They emphasized that staff welfare remains a top priority and that any form of harassment was taken seriously and would be addressed without delay.

Staff were recruited from a range of diverse backgrounds, reflective of the local community. Observations confirmed respectful interactions and effective communication among team members. Staff reported positive working relationships and a strong sense of teamwork.

Management consistently supported staff requests for changes to contractual hours, demonstrating flexibility and consideration for individual circumstances. Initiatives such as the "Carer of the Month" scheme encouraged peer recognition and celebrated staff contributions to both care delivery and team support.

The management team actively encouraged staff to celebrate and take pride in their individual cultures. Examples included staff bringing in food to mark cultural and religious events such as Eid, Diwali, Easter, and Christmas. These celebrations were inclusive, with participation from people using the service and their families, fostering a positive and welcoming atmosphere.

Staff expressed appreciation for the inclusive culture and noted plans for additional cultural days to further promote diversity. Feedback indicated that managers were perceived as fair, supportive, and committed to maintaining an inclusive workplace.

The provider did not always 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.

The provider was found to be in breach of regulation 17 (Good governance) at the previous inspection. While some improvements had been made, we found further governance concerns at the service. As a result, the provider remains in breach of this regulation. The provider was proactive and transparent throughout the inspection and agreed that further work was required to ensure any changes or learning needs to be fully embedded into the daily operations of the service to ensure compliance with governance.

The registered manager and staff had undertaken a range of audits prior to the inspection. However, these audits did not identify several significant issues that were subsequently found during the inspection, as detailed elsewhere in this report. The checks and audits failed to detect and address critical shortfalls, for example safety deficiencies within the physical environment, risks to the safety of people using the service, inadequate oversight of records relating to dietary and fluid intake, care documentation, and medicines management.

Although many of these concerns were addressed during the inspection, the provider’s internal audit processes had not previously enabled them to identify them and address them in a timely manner. Additionally, the audits lacked detailed analysis, which limited the ability to provide assurance regarding actions taken to identify lessons learned.

An environmental audit conducted by the regional maintenance team on 5 September 2025 identified several areas of concern, for example fire doors closing slowly, unsafe clinical storage located outside in the front car park and a kitchenette on the first floor requiring replacement due to water damage and mould.

At the time of the inspection, 3 weeks after the above audit, we found these issues remained unresolved. This indicated limited oversight and follow-up to ensure that identified actions were completed, thereby compromising the safety of both people and staff. The ineffective monitoring processes meant the provider lacked an accurate understanding of the environmental safety standards within the building.

Following the inspection, the provider took prompt action to address the concerns raised, adding these to an action plan. These actions significantly reduced the risks to people using the service. However, the provider’s governance and oversight mechanisms in place were found to be insufficiently robust.

Moving forward, the provider assured us the area manager would continue to provide weekly support to the service to strengthen governance and ensure that future audits are both effective and sustainable.

As a direct response to the inspection findings, daily walk-around checks were introduced at the service and unannounced spot checks were carried out, including on weekends. Records confirmed that no further concerns were noted during these checks.

The outcomes of the inspection were communicated to staff by the provider, along with details of the actions taken. Furthermore, the provider informed us learning from the inspection would be embedded into staff practice through inclusion in all staff supervisions and team meetings.

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.

The service had established good working partnerships links with the local GP surgery with face-to-face ward rounds had been implemented following engagement by the registered manager. The service had established good links with other professionals, teams and agencies, such as district nurses, tissue viability nurses and speech and language therapy. Healthcare professionals we spoke with confirmed this and told us they had good working relationships with the service.

Staff ensured referrals were made to a wide range of external agencies and professionals as required. A healthcare professional told us staff made appropriate referrals to their service as needed and that staff attended any training they organised. We saw feedback from another professional about how openly staff had worked with them to ensure a person’s safety.

Staff engaged with the local community. For example, the local vicar visited and there were garden parties and Christmas parties held at the service. Staff also took people to the local school to listen to the children singing.

A trip had been organised for a person to visit the studio of a local radio station and arrangement have been made for a wheelchair taxi and staff to accompany on the visit.

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, effective practice and research.

The quality assurance processes in place were not fully robust and had not consistently identified areas of risk. They had not always identified those aspects of the service which required improvement, nor had they always ensured the areas identified as in need of improvement had been promptly addressed, as evidenced by the issues we identified at this inspection.

The management team acknowledged the shortfalls identified during the inspection. They demonstrated a proactive approach by initiating immediate actions to address the concerns raised. Following the inspection, the registered manager confirmed the implementation of a comprehensive Service Improvement Plan, which was shared with us. This plan addressed all areas identified during the site visits and included details of actions taken or scheduled for implementation.

The provider had systems to monitor and mitigate risks; however,’ we found no documented evidence on lessons learnt to prevent incidents from happening again. The provider conducted an analysis of accidents and incidents, and some measures had been put in place as a result. however, they failed to keep records on how lessons had been learnt to help keep people safe from further injuries.

Staff had team meetings to discuss the running of the service and told us they were listened to, and their feedback was taken on board. Staff received regular training and updates, and records showed training compliance. Staff told us they could request additional training if required. For example, one staff member said, “If you need more training, then they will provide it. Or, if we have done the training but feel we need more, they will provide further training.”

The manager had an open-door policy and told us they welcomed feedback to support the service. The manager shared some success stories to note how they supported people to improve their health and wellbeing that positively affected their lives.