Fitzwarren 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 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.

This service scored 57 (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 always demonstrate a shared culture based on transparency, openness and inclusion.

Feedback from staff raised concerns about aspects of the culture and told us they did not always feel comfortable challenging practice. Staff also told us that when they had raised concerns, they did not feel these were always addressed. While these views were not shared by all staff, they indicated that the provider could not be fully assured that an open and transparent culture was experienced consistently across the service.

Nursing unit leader was described as knowledgeable about people and the service. Nursing unit staff at all levels demonstrated an understanding of the importance of providing safe, compassionate and person-centred care. Staff spoke positively about the culture within their team and described unit leader as approachable, visible and supportive. They told us they felt valued, treated fairly and able to raise concerns or seek support when required.

People also told us staff treated them with kindness and respect and supported them in ways that reflected their individual needs and preferences.

Leaders did not always demonstrate effective oversight to ensure improvements were implemented and embedded in a timely way. Although the provider's senior leadership team had identified several areas requiring improvement through their quality assurance processes, some issues remained unresolved at the time of our assessment. For example, actions to reduce risks associated with the use of paraffin-based emollient creams had not been fully implemented despite this having previously been identified as requiring further action. A manager told us the home had experienced a number of recent system and process changes, and progress in implementing these had been slower than anticipated.

Leaders were able to describe the actions they had taken to monitor quality and drive improvement and demonstrated an awareness of the service's strengths and areas for development. During the assessment, managers were open and transparent when discussing challenges and acknowledged where improvements were needed. The provider's own quality assurance processes had identified several of the issues found during the assessment, showing that leaders had systems in place to review service performance. However, further work was needed to ensure identified actions were implemented effectively and resulted in sustained improvements for people using the service.

The provider did not consistently foster a positive culture where staff felt able to speak up and have their views heard. Some staff told us they did not feel comfortable expressing concerns or speaking openly with us during the assessment. This indicated staff did not always feel confident that concerns could be raised without negative consequences.

Staff feedback was mixed. While some staff told us they felt confident raising concerns and believed leaders would listen and take appropriate action, others were less assured. Some managers were described as approachable and supportive, and several staff said they would feel comfortable escalating concerns where necessary.

The provider had a whistleblowing and speaking-up policy in place. Information about how to raise concerns was available to staff, and posters promoting speaking up and whistleblowing were displayed throughout the service. Staff demonstrated an awareness of reporting processes and the support available to them if they wished to raise concerns.

Although the provider had systems and processes in place to promote openness and transparency, these had not been consistently effective in creating a culture where all staff felt comfortable speaking up. As a result, an open and positive speaking-up culture was not fully embedded across the service.

The provider did not always demonstrate that it promoted an inclusive and fair culture for all staff. Concerns had been raised regarding equality and fairness within the workplace; however, the provider had not always responded to or addressed these concerns in a timely manner. This meant leaders could not demonstrate that all staff concerns about fairness and inclusion were consistently acted upon.

We discussed these concerns with the management team. They confirmed they were aware of the issues raised and advised that an investigation was due to commence on the day of our assessment. This indicated that concerns had been identified, although action had not always been taken promptly to address them.

Feedback from staff was mixed. Some staff told us they felt they were treated fairly and equally and spoke positively about the support they received from managers. The manager described how policies and procedures were used to promote equality, diversity and inclusion within the workplace. They provided examples of reasonable adjustments being made for staff with health conditions and explained the processes in place to identify, investigate and respond to concerns relating to inequality or discrimination. These systems were in place; however, they had not always been effective in demonstrating concerns raised by staff were addressed consistently.

The provider did not have effective governance arrangements to ensure risks were identified, acted upon and monitored effectively. They did not always act on the best available information regarding risks, performance and outcomes, or ensure information was managed securely.

We identified 2 occasions where people's personal information was not stored securely, meaning unauthorised individuals had access to private and confidential information. We raised these concerns with managers during the assessment, and they were addressed on the same day.

Records showed the provider's own audits had previously identified similar concerns relating to information governance and record storage. Although staff had been reminded of the correct procedures, the recurrence of these issues indicated actions taken had not been fully effective in embedding and sustaining improvement.

Audits had highlighted incomplete or missing documentation, including admissions records, care plans and risk assessments. Records did not consistently demonstrate what action had been taken in response to these findings or whether improvements had been followed up and sustained. For example, some PRN (as required) medicine protocols had review dates that had passed without being updated.

The provider had an audit schedule in place and completed a range of regular audits. The provider's senior leadership team had also identified areas requiring improvement prior to our assessment, demonstrating that systems were in place to monitor performance and identify concerns. However, some issues remained unresolved at the time of our assessment, indicating that governance systems were not always effective in driving and sustaining improvements.

A manager told us governance processes had recently undergone a number of changes and that progress in implementing these had been slower than anticipated.

The provider could not be assured that actions identified through audits were consistently implemented, monitored and sustained, or that information was always managed securely and confidentially.

The provider demonstrated a proactive approach to collaboration and partnership working to support people's care and treatment.

Professionals described working relationships as positive and told us the service engaged with them appropriately when concerns or areas for improvement were identified. They said management and staff were receptive to feedback, guidance, and professional challenge when required.

A healthcare professional told us, "The provider works well with us, and we have very good relationships that combine to offer a good service to the people." They also said that when visiting the home, they and their colleagues were treated respectfully and made to feel part of the wider team.

The provider demonstrated a focus on learning, innovation and improvement across the organisation. The provider was able to demonstrate involvement in innovation and improvement initiatives. Leaders told us the organisation was participating in Parkinson's research projects and described how this supported the development of knowledge and practice across the service. This demonstrated a commitment to developing care and identifying opportunities for improvement.