Hepworth House

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 remained Requires 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 governance at the service. The providers governance systems were ineffective in identifying and driving improvements in the service. Governance systems had not identified the concerns highlighted during this inspection.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a clear shared vision, strategy and culture based on transparency, equity and equality. Although staff and leaders we spoke with told us about promoting people’s independence and providing opportunities for positive outcomes, we did not find this was always occurring in practice. For example, Safeguarding concerns were not always identified and reported; we identified significant concerns in reporting incidents and accidents, and debriefing and supporting staff. These increased risks of the service not always having a positive listening culture.

The service did not demonstrate they had capable and compassionate leadership. During this

assessment, we identified breaches of the legal regulations. This meant leaders had not always

identified and taken action to ensure people received care that was in line with legal

requirements. However, overall, staff felt they could approach leaders with any concerns they

had and told us how the registered manager and nominated individual were present and would

help out regularly. A staff member said, “[Registered Manager] is very approachable. Another

told us, [Registered Manager] and [Nominated Individual] are always around, anytime we can

talk to them.” People and relatives knew who the management team were and said they were

visible and approachable in the service.

Due to our findings in relation to incidents and safeguarding concerns not always being

identified, we could not be assured people and their relatives would be informed of these

promptly and would be given an apology when things went wrong. However, People and their

relatives did not raise any concerns about being unable to speak up.

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. Many members of the

staff team had worked in the service for a number of years and told us they enjoyed working in

the service.

The service did not have good governance systems in place. They did not act on the best information available to them about risk, performance and outcomes. The provider had not identified concerns related to safeguarding, managing risks, medicines, the safety of the environment, care planning and ensuring people were always treated with dignity and received person-centred care. We found people were at risk of being exposed to harm during this inspection.

The provider didn’t always understand the importance of working together to make sure services

ran smoothly for people. They didn’t always share information or work with others to improve

services. For example, when people’s emotional distress increased, the provider didn’t contact

professionals in a timely manner for support. Safeguarding concerns were also not reported to

external agencies, which prevented learning from taking place

The provider did not always focus on continuous learning, innovation and improvement across

the organisation and local system. There were no systems in place to capture incidents and

adverse events, this meant systems to analyse for themes and patterns to improve care delivery

were ineffective leading to poorer outcomes for people. Despite our findings, the provider was

responsive to our concerns and feedback and started to make immediate changes to drive

improvements in the service.