Friars Mead

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.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The manager had not promoted a culture of transparency. Throughout the inspection, we identified notifiable incidents and deaths which were not reported to CQC. An outbreak of flu had not been reported to UKHSA as required.

We reviewed team meeting minutes and found staff were discouraged from raising issues with external visitors. For example, the minutes stated: “Staff must not share operational complaints or internal issues with external visitors. Comments such as 'that's been broken for months' or 'no one's done anything about it' can trigger unnecessary safeguarding investigations or regulatory action.” However, staff described a positive working environment where they felt supported by managers and colleagues. A staff member said, “The management team is very knowledgeable, welcoming, educative, friendly and supportive, not only to the residents but to the staff as well.” Another staff member told us, “The staff are respectful and considerate, and they prioritize the well-being of those they support.”

The manager appeared to have the skills and knowledge to lead effectively. It was unclear why regulatory obligations had not been followed. Following delays in responses from the manager, and notifications not submitted, we contacted the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. Whilst they described some ongoing challenges for the service, they did not offer an explanation as to why notifications had not been submitted as required and admitted there was very little support available to the manager.

The manager told us they met with the nominated individual for supervision and board meetings and found them helpful. They said, “Yes, they are busy, but I always know I can get hold of them.” Board meetings included discussions of incidents at the home, so it is unclear why the provider had not identified the lack of notifications.

People and relatives were happy with how the home was managed. A relative said, “I have no issues with the management of the home…If [person] is upset when I visit and they can see I am upset when I leave, they are really comforting and I get a text later telling me that the situation has calmed down.”

The provider had a procedure for staff to speak up. We requested the provider’s whistle-blowing policy and received the ‘raising a concern with CQC’ document from the CQC website. This is generic guidance and does not include internal contacts for staff to escalate concerns within the service. However, there was information displayed on noticeboards throughout the service.

Staff confirmed they knew who to report their concerns to and felt these would be addressed. A staff member said, “I know who to speak to, and I feel confident that my concerns will be taken seriously.” Another staff member told us, “I know who to speak to if I have concerns, and I feel comfortable raising any issues.”

Whilst staff gave positive feedback about working at the service, and told us they would raise issues, we were concerned about comments in the team meeting minutes which appeared to discourage them from raising concerns externally: “Staff should use correct internal reporting channels and allow management to communicate with external parties appropriately.”

We fed this back to the manager who told us they advise staff to come to them first as they may have information the staff member does not. They said, “There’s never been an issue where we’ve stopped them. We always say come and see us first but go outside if not acted on. The reason we say not to is where we may know something they do not. We remind them to come and see us first.”

Following our inspection, we were told the minutes of the meeting were amended and staff were reminded of their right to raise concerns externally.

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 had policies to support fair treatment of staff. Staff gave positive feedback about support from managers and colleagues.

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, performance and outcomes, or share this securely with others when appropriate.

The manager was unable to locate documents on their system to demonstrate their oversight of the service during both our visits. Following our visits, they did not share information with us in a timely way.

The manager did not collate incidents, safeguarding concerns or complaints for analysis. This meant we were not assured themes were identified and acted upon.

The provider’s audit program was not always effective. It did not include an audit of recruitment files meaning the gaps we found were not identified. Whilst care records were reviewed, they had not identified the discrepancies we found. However, we reviewed audits of health and safety, medicines and infection control and saw issues were identified and actions taken.

Staff were not recording people’s food and fluid intake consistently. We saw in staff meeting minutes from November 2025 this had been raised with staff. However, it remained an issue during our visit meaning the action was not effective.

Following our visit, various governance documents were created. These included a checklist of actions in response to falls and malnutrition risks. Another document included an audit program and list of policies with due dates as well as monitoring of health and safety requirements such as equipment servicing. The manager told us, “I will continue to use the tracker for ongoing governance and develop the use of this information, ensuring that when you or others need it, we can readily refer to it.”

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners and collaborate for improvement.

Staff had good relationships with other professionals who visited people in the home. A professional said, “I have always enjoyed my visits there and communicated well with the staff and leadership team.” Another professional said, “I have a good relationship with both the management and care staff at Friars Mead.”

The manager had not always shared information with external organisations as required.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and the local system. We were not assured there were processes to ensure lessons learned when things went wrong. They did not always have strong relationships with external stakeholder to drive improvements.

The nominated individual told us the manager was working on improvements to the home. They said, “We have invested heavily over the last 2 years in systems and processes to modernise and de-risk the home.”

The manager had implemented electronic care records and was working towards electronic medicines administration records. There were also plans to implement falls monitoring technology. The manager told us, “I am very proud of my home and aware of the progress we’ve made since I took on this role, especially in bringing things into the digital age. Previously, everything was paper-based—care plans, staff files, training records, and more. My goal is to build on our current systems to make our home even safer, more effective, responsive, well-led, and, most importantly, caring.”