Florence 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 the last inspection this key question was rated good. At this assessment this key question has changed to requires improvement. This meant people's needs were not always met.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager was visible within the service. Staff told us they felt supported by the registered manager. One member of staff told us, “I really like the team and the manager. The manager is very supportive and has a bon with the residents and knows how to support them.” Another staff member told us, “I like working here because of how much support I receive. There is a lot of understanding and commitment between the manager and staff.” Whilst the staff we spoke to expressed they were happy with management, our assessment found elements of processes did not meet the expected standards.

The registered manager was clear about their roles and had the skills, knowledge and experience to perform their role. The registered manager felt supported by the provider. However, we found limited evidence to show the provider had carried out robust audits and processes. The audits carried out by the provider lacked detail and were mostly a tick box exercise. We were not assured the provider had good oversight of the service.

Staff were positive about working at the service and promoting good outcomes for people. One member of staff told us, “We all work well together, and we all support each other. I have a supervision ever 3 or 4 months and we discuss how we feel working here, the people we support, health and safety and any other issues or concerns we have.” Another member of staff told us, “The residents have meetings with the manager. The manager checks on them and how they are feel living here and if there is anything they want to improve on. We also look at menus and any issues with staff and how the residents are being supported.”

Staff meetings were being held regularly. We reviewed minutes and saw they included information about the service as well as reminders about training, staff rota’s, safeguarding and PPE. However, there were no action plans completed to evidence how issues raised were to be addresses, dates to be achieved and if actions had been resolved or remained outstanding. The registered manager told us they carried out regular resident meetings. However, the registered manager was unable to provide evidence of the resident meetings that took place. The registered manager sent surveys to people using the service to gather feedback about the service and discussed feedback with people who used the service. However, there was no formal record of discussions that took place following the survey.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff told us they had regular supervisions and felt supported by the registered manager. However, completed staff supervisions kept on staff files had not been signed off by staff. The registered manager told us they felt supported by the provider. The provider carried out 4 meetings a year with the registered manager.

The quality assurance and governance arrangements in place were not always effective in identifying shortfalls at the service. For example, no system was in place to make sure staff's recruitment files, induction, training and supervision data were audited to ensure these were in line with regulatory requirements. The registered manager told us they completed regular audits. However, there was no evidence to support this. This meant effective auditing arrangements were not in place to assess, monitor and improve the quality and safety of the service provided and lessons learned. There was no formal record for how the registered manager learnt from lessons following incidents. The service did not have a service improvement plan in place. A service improvement plan includes checklists and examples to help you to identify what your service needs to improve, and to develop an action plan to implement the required changes. Effective systems to monitor and improve the quality of the service were not in place. This was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.