The Firs Residential Care Home

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 changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulations in relation to people’s safe care and treatment and governance at the service.

This service scored 25 (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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion and engagement. Whistleblowing concerns from staff and feedback received from staff during the assessment demonstrated their concerns over a closed culture. A closed culture is described as a poor culture in a health or care service that increases the risk of harm. Staff told us they had limited communication with the registered manager and did not receive regular supervision or competency checks. Records provided to the commission supported what staff had told us.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty. The registered manager acknowledged the concerns and failings we found surrounding training and support for staff but repeatedly disagreed that this affected staff’s ability to support people safely. Staff and relatives told us there was a blame culture within the home. One relative said, “I spoke to the registered manager about some of the concerns the CQC found, they told me it was a specific staff member’s fault. I was shocked at the response and felt this was unfair and unprofessional.” Another relative said, “I feel for the staff, they are so good with [name] but they don’t get any support, I am here most days and we hardly ever see a manager.”

People did not feel they could speak up and that their voice would be heard. Staff told us they knew how to raise concerns but were unable to raise their concerns to the provider about the registered manager. One staff member said, “There use to be a director onsite and we could go to them, but now there is no one.” Another staff member said, “I did raise my concerns with the [registered] manager it was awful they just ignored me from then on for about a week.” During the assessment we raised multiple concerns to registered manager. We failed to see the registered manager personally interact with any staff member or support them to make improvements. We saw evidence of the registered manager communicating with the staff team via electronic messages requesting information on which staff members were responsible for the failings and concerns we had raised. This supported a closed culture and staff inability to speak up confidently and freely.

Despite numerous requests we were not provided with any documentation to support workforce equality, diversity and inclusion, this included policy and procedures, complete and accurate training and competency records, team meeting minutes and audits and action plans.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Quality monitoring processes and audits such as competency checks, manager walk round, and monthly audits were still not routinely undertaken and the provider and management team did not have oversight on the quality of care people were receiving. Where the limited audits undertaken had identified issues the registered manager had failed to act on the concerns found. For example, a failure with the emergency lighting in the home had been identified in December 2024. Emergency lighting aids people in an emergency event such as a fire, to locate exits quickly. At the time of assessment these repairs had still not been completed. The registered manager and provider acknowledged they had been aware that the external retaining wall was structurally unsafe and a risk to people as it could collapse. However, after 1 month no further progress had been made to ensure the wall and area was made safe or repairs could commence. This meant that ineffective governance placed people at the risk of harm from the environment and unsafe care and treatment.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. As evidenced in the report, professionals who worked with the service raised repeated concerns about the presence of the management team. While everyone we spoke with told us staff supported and aided partnership and community working, they were limited in their action and responses for improvements or changes without management support or agreement.

The provider and registered manager did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not actively contribute to safe, effective practice and care delivery. The culture of the home and oversight processes in place to monitor the service failed to identify or act on concerns including staff training and upskilling, the unsafe environment, fire safety risks and poor care planning which meant people were at risk of receiving unsafe care. For example, concerns were identified that people, including those living with dementia, had access to unlocked or easily unlocked doors that were not alarmed and could leave the property unsupervised. People faced risks of a main road to the front of the property and access to a single storey roof at the rear of the property with placed them at risk of harm. Staff told us they had repeatedly raised these concerns, but no action had been taken. We discussed this with the registered manager who had not identified these risks. They did take some action to address the concerns, but this action did not fully mitigate the risk. People remained at risk of falls or absconding from unsupervised access to external doors. This demonstrated that learning and improvement had not been embraced by managers or embedded into the service.