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

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 requires improvement. At this assessment the rating has changed to good.
This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.
The service was no longer in breach of legal regulation in relation to the management of safety and governance at the service. Which meant concerns relating to the management of safety and governance had improved.

This service scored 71 (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.
Leaders promoted a clear and shared direction through defined values centred on safety, openness, staff development and improving people’s quality of life. Staff understood these values and applied them in their day-to-day work. They described managers as approachable, supportive and responsive, which helped create a positive and inclusive culture.
Staff worked well as a team and supported each other, including new colleagues, which promoted consistency in care. Managers held regular staff meetings and daily “flash” meetings to share information, reinforce expectations and provide opportunities for staff to raise concerns. One staff member shared “Lessons learned are shared in flash meetings where we can all talk about mistakes and share learning.”
Leaders recognised previous challenges with staff morale and took proactive steps to address these. They increased management visibility, strengthened staff engagement and created more opportunities for staff to share their views, including social events.

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.
Managers maintained a strong and visible presence within the service, building positive relationships with people, relatives and staff through regular engagement. They showed a clear understanding of the service, identifying areas for improvement and took timely and effective action to drive positive outcomes.
Staff consistently described leaders as approachable, supportive and responsive. They felt encouraged to raise concerns and share ideas and told us leaders listened and acted on feedback. This promoted a positive, open and inclusive culture where staff felt valued and respected. One staff member told us, “I definitely feel supported by the leadership team it doesn’t matter whether this is work related or in my personal life, there is always a solution provided for this.” Another staff member shared “The managers listened to when I raised concerns about the needs of one person who was admitted, so an extra member of staff was rostered.”
Relatives also spoke positively about the management team, describing them as accessible, caring and responsive to their needs. The registered manager strengthened this approach through regular initiatives such as “Drop-in Wednesdays,” which provided a welcoming and informal opportunity for people, relatives and staff to share feedback and contribute to the continued development of the service.
 

The provider fostered a positive culture where people felt they could speak up and their voices would be heard.
The provider promoted an open culture where people, relatives and staff could raise concerns freely. People and their relatives told us they felt confident approaching management; one relative said, “You can knock on the manager’s door at any time,” and another described the management team as welcoming and focused on residents. In response, to feedback from staff leaders held drop-in sessions, met with staff, displayed whistleblowing information across the service and maintained a visible presence to encourage open dialogue. Staff we spoke to confirmed they felt able to speak up and described the service as a positive place to work.
The provider encouraged openness and continuous improvement by seeking feedback from staff and families through meetings and surveys. ‘You said, we did’ information was displayed, demonstrating responsiveness to feedback. Although survey results were not yet available, this approach showed a clear commitment to listening and improving the service.
The provider actively encouraged feedback and demonstrated learning through ‘You said, we did’ communications following relatives’ meetings. They logged and investigated complaints appropriately, and the registered manager followed duty of candour principles, showing openness and transparency in responding to concerns.
 

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 strong commitment to promoting equality, diversity and inclusion within the workforce. They embedded these values through effective systems, processes and training, which supported a respectful and inclusive working environment.
The service recruited staff from diverse backgrounds that reflected the local community. Staff worked well together and communicated respectfully. They told us they felt part of a supportive and inclusive team.
Managers showed flexibility by accommodating staff’s individual needs, including changes to working hours. They recognised and valued staff contributions through initiatives such as the “Employee of the Month” scheme.
The management team actively promoted cultural awareness and inclusion. Staff celebrated a range of cultural and religious events, including Eid, Diwali, Easter and Christmas, involving people using the service and their families. This created a positive and inclusive atmosphere.
Managers supported staff to succeed through reasonable adjustments and additional guidance where required. Clear roles and responsibilities ensured staff felt valued for their individual strengths.
The provider promoted equality and diversity, supported by clear values set out in their statement of purpose.
 

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.
At the previous inspection, the provider was in breach of Regulation 17 (Good governance). At this inspection, leaders demonstrated clear improvements and were no longer in breach of this regulation. They strengthened governance processes and took a proactive, transparent approach to driving improvement.
The registered manager with the support of leaders had implemented a range of audits and checks and increased their oversight of the service. These checks and audits provided improved oversight across the service which supports the timely identification and management of risks, including those related to the environment, people’s safety, dietary and fluid monitoring, care documentation, accidents and incidents infection control and care plans and medicines management.
We found governance had improved; however, systems did not always identify issues promptly. This was evident in communication and documentation relating to new admissions and choking risks.
Although audit processes had improved, some gaps remained. Audits did not consistently identify all concerns. There were gaps in the supervision matrix and limited oversight or auditing by the registered manager of those conducting supervision. Additional training has been arranged for managers, with further checks and audits introduced by the registered manager. Overall, governance systems require further strengthening to be fully effective.
Audits had also failed to identify kitchen hygiene concerns, which contributed to a reduced hygiene rating following an inspection and a suspension by commissioners. The provider acted immediately, completed all required actions, and introduced strengthened audits and oversight, including a floating head chef role and increased delegation to service managers.
Management responded proactively by addressing these concerns and implementing improved systems and processes to strengthen oversight and support sustained improvement.
The provider met their regulatory responsibilities by notifying CQC of significant events.
 

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 demonstrated effective partnership working with healthcare professionals and community services. The registered manager worked collaboratively with a local GP practice to introduce weekly ward rounds led by a community paramedic and GP. This approach reduced the use of emergency services and hospital admissions, helping to minimise distress for people, particularly those living with dementia.
Staff showed improved knowledge and confidence in identifying deterioration, completing monitoring and making timely referrals. They escalated concerns appropriately and ensured relevant information was available to support clinical decision-making during ward rounds.
The service maintained positive working relationships with a range of professionals, including district nurses, tissue viability nurses and speech and language therapists. Feedback from professionals confirmed staff worked openly and collaboratively and made appropriate referrals when required.
The service also engaged with the local community. For example, they organised a dementia awareness event to support people, staff and community members to better understand the impact of dementia.
 

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 provider demonstrated a proactive and increasingly positive approach to learning from incidents and improving practice. Lessons learned from call bell audits, falls and choking incidents were routinely analysed and shared with staff through team meetings and supervision sessions. For example, call bell audits led to improved response times and greater staff awareness of people’s needs, while learning from falls incidents supported more effective risk assessments and preventative measures such as increased monitoring and environmental adjustments. Following a choking incident, staff received additional guidance and training to improve awareness of safe eating practices and escalation procedures, which strengthened people’s safety.
The registered manager actively engaged with managers from sister services through regular meetings, enabling wider learning to be shared and embedded across the organisation. For instance, shared learning relating to choking risks and hygiene standards resulted in the introduction of enhanced safety measures and improved practices within the service. These changes reflected a positive culture of continuous improvement. The provider should continue to build on this progress to ensure all learning is consistently embedded and sustained in everyday practice.
The manager maintained an open and inclusive culture, encouraging feedback from staff and relatives through an open-door approach. They demonstrated a clear commitment to improving people’s outcomes and shared positive examples of this. For instance, the manager described how staff supported a person following a stroke to improve their health and wellbeing, which had a meaningful and positive impact on their quality of life.