Figham 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 the same. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. This was a breach in legal regulation relating to good governance.

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 service 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 core values of the service were shared on noticeboards throughout the home. These emphasised ‘kindness, celebrated quality care, respected individuality and identity, and asked staff to make a positive difference every day’. One staff member told us, “I enjoy giving care to [people]. It’s really rewarding making a person’s life better.”

Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. Poor practices observed during our inspection visit had not been identified or raised by senior staff, despite them occurring in the main lounge in view of the seniors’ office. Areas for improvement identified at our last inspection visit had not been recorded, tracked or completed. Although the registered manager undertook a regular walk around to check the environment of the service, these had failed to identify the concerns we observed. The registered manager had not taken action or tracked required actions from audit recommendations. The registered manager had not identified the changes required in the home to ensure best practices in relation to, for example, donning and doffing, had been updated. The management team were visible within the service and knew people, relatives and staff well. Staff were recruited safely. Staff told us they received regular supervision and support. One staff member told us, “We are being supported by seniors or management.”

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Posters were displayed showing the ways in which staff could speak up. Staff confirmed there was an open culture within the home and meetings took place regularly. A staff member told us, “Staff meetings are more in depth, and we are able to voice our opinions. (We) discuss anything that needs to be changed in the way we work rather than it coming from the top.”

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. The service had policies in place to ensure staff were treated equitably. Staff were aware of these policies and confirmed the service was inclusive. Staff were treated fairly. A staff member told us, “I feel really supported and the team are all there for each other.”

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. A schedule of quality assurance checks and audits took place. However, these were not effective and had not identified the concerns found during our inspection visit. For example, care plan audits had not identified the need for further detail in people’s moving and handling care plans, nor had they identified generic risk assessments were not appropriate. Where concerns had been identified within the provider’s own audits, these had not been acted upon in a timely manner. For example, a recent dining audit identified a lack of choice for people about how much gravy or sauce they had added to their meals. During our inspection visit we observed gravy and custard continued to be added to people’s meals without them being given a choice. Staff told us the service was well-managed.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement. The service worked in close partnership with a number of different community groups, collaborating, for example, with a variety of local churches and also the local brownies. People undertook regular outings into the community.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. Required improvements identified at the last inspection had not taken place. Some of the recommendations from an Infection Prevention and Control audit the previous year had not been actioned. The service undertook regular care plan audits each month but had failed to identify the omissions found during our inspection visit. A recent quality audit about the dining experience had identified two recommendations but the required actions had not been undertaken or monitored.