Frindsbury 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 good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider 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.

People, relatives, staff and healthcare professionals told us there was a positive culture at Frindsbury House. Relatives described a homely feeling, where they were always welcome. A relative told us, “They [staff] always make us feel at home too.” A healthcare professional told us, “I feel the service is not only safe but a very lovely and caring home. It is always a pleasure to visit there and work with their patients. I have been in many care homes in my time, and this is one of, if not the best.”

Staff were happy, and understood the people, and their relatives they supported. A healthcare professional told us, “They appear like a good team. They are interested and do their best to give them the best quality of life. It’s a pleasure to go there.”

Leaders at the service were passionate about the care they provided. The manager told us, “We are very proud of the service we provide and the people we support” and, “This is a very unique environment, and our common goal is to ensure the best possible quality of life for everyone here. This passion and positivity is shared by all the staff including catering and service staff.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

At the time of our inspection there was no manager registered with the CQC. The service was led by a manager who ran the service day to day, who was supported by the director of care, who had applied to be registered with CQC. Feedback we received about the leadership of the service was positive. A healthcare professional told us of the manager, “She has always seemed professional. She's always very caring.”

The manager, and leaders at the service were knowledgeable of people, and their relatives and what was important to them. Leaders had years of experience supporting people with Huntingdon’s and were skilled and empathetic towards people. We found that leaders had conducted themselves with integrity, acting with the best interests of the people they supported with openness and honesty.

People did not always feel they could speak up and that their voice would be heard.

Although all staff we spoke with told us they would confidently speak up, we found they had not always done so. When a concern had been identified, we found leaders took action, and staff had recently completed training to encourage them to use their voice and share concerns with leaders. They told us they now felt staff would come forward if any concerns arose. One staff member told us, “I feel as though I am able to speak up at any time about anything that concerns me or that I feel needs changing or addressing.”

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.

Diversity was celebrated at the service. Staff had completed training on diversity and inclusion. Staff completed anonymous staff surveys to share their views on inclusion, workplace culture and any barriers affecting the workforce. The feedback informed improvements to communication methods, staff support systems, career development pathways and succession planning.

One staff member told us that leaders had supported them following a recent diagnosis. Staff told us they felt comfortable to share this information with leaders and had received the support they needed which made them feel valued.

The provider had a number of checks and audits in place to review and improve the quality of the service. However, these had not always been successful at identifying issues, found at this inspection. When the provider was made aware of issues, they took immediate action to learn and improve their systems. However, concerns including medicines administration, reviewing of care plans and risk assessments and ensuring PEEPs were up to date had not been completed. Some mental capacity assessments (MCA) had not been reviewed or updated since April 2025.

Other checks and audits were successful in identifying and improving shortfalls. The provider was open to learning and implemented improvements immediately. They told us, “We are always willing to learn and make improvements.”

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Leaders and staff worked to ensure that people were part of the community. Staff hosted events regularly, inviting family, friends and people from the providers other service to encourge people to make connections. Several people and relatives mentioned the events held. A relative told us, “The event was absolutely fantastic, it’s a shame it rained but we were under gazebos, they do a cracking job down there, they go all out for their summer party.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

There were systems in place to learn and improve. Incidents were reviewed and lessons learnt were implemented and shared with staff. Following a safeguarding concern, the provider took extensive action to learn and improve, reviewing practices and processes to try to reduce the likelihood of the incident re-occurring. The manager told us, “We share the learning from incidents both in staff meetings and at handover, also to individuals if necessary.”

Staff strengths were recognised and used as an opportunity for improvement and learning. For example, the deputy manager was passionate about learning and development and had been involved in reviewing and updating training programs for staff.