The Firs Residential Home

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• 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 good. At this assessment the rating has changed to 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.

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 registered manager and provider had a visible presence in the service and encouraged people, staff and relatives discuss any concerns they had. Staff told us how staff meetings allowed for discussion and reflection on key issues. Staff were able to contribute their ideas and any concerns during these meetings. We also found resident meetings regularly took place and where people made suggestions for activities and events, and these had been actioned by staff. Relatives spoke positively about the culture of the service and told us they found staff friendly, encouraging and responsive to people’s needs.

Staff consistently told us the registered manager and provider were approachable and managed the service well. One staff member told us, “Truly, the manager and director are people you can speak too, they listen and are always around.” And another staff member told us, “The manager is really nice, helpful and friendly.” The registered manager told us since they had been in post, they had ensured staff had been included in changes they had implemented such as ensuring each staff member had the individual support they required on the transition from a paper-based system to electronic system of records. Whilst leaders of the service led staff to ensure that the care provided to people was person centred and based on people’s individual need well, they were not as robust in using their governance processes and outcomes when leading the team. This was being developed and embedded at the time of the assessment.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff understood how to speak up and raise concerns and they told us they felt they would be listened too. Staff were also knowledgeable on how to raise concerns outside of the service to the Care Quality Commission, police and local authority.

Systems and processes were in place for staff to discuss any concerns this included staff meetings, supervision’s and in person with the manager or provider.

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. Staff told us they were treated fairly. Staff had received training in equality, diversity and inclusion and we observed staff put this into their practice throughout our assessment. Relatives told us their family members were included by all staff. One relative told us how their family member’s preference was to spend time in their room and how staff regularly went into chat with the person about their interests.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk. We found the service lacked effective systems and processes to aid the management oversight of the service. We found audits completed had not identified the issues we found with the management of medicines. We also found risk assessments had not thoroughly considered the potential hazards we found in the service in respect of the portable heaters or stair gates in use. The provider's systems had also failed to identify and consider when mental capacity assessments, best interest decisions and DoLS authorisations should be considered in respect of people’s consent. The registered manager told us of their plans to introduce a more comprehensive auditing system to aid their oversight of the service, however this was not in place at the time of our assessment. Systems and processes in place had not assessed or mitigated the issues we found within the environment prior to the provider’s refurbishment plan commencing. We found no evidence that people had been harmed, however, systems were either not in place or robust enough to demonstrate governance was effectively managed.

Staff worked with external professionals to ensure people’s changing needs were met. Established systems were in place to ensure timely referrals and advice was sought in respect of people’s health when this was required. We spoke to a visiting professional who confirmed they had no concerns regarding the quality of care provided.

Staff told us they felt they were involved in decisions and encouraged to share ideas to continue the development of the service. The provider had recently introduced a new electronic care system for recording information about people to improve the efficiency of monitoring people’s health and wellbeing. Whilst it was working well it was still in its infancy and they were not using the system as they could to review outcomes for people. The registered manager told us of the systems and processes they had introduced since been in post and how they were committed to ensuring continuous improvement in the service.