Fryers House - Care Home with Nursing Physical Disabilities

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 provider was previously in breach of the legal regulation in relation to good governance. At this assessment, we found the provider had not made sufficient improvements in relation to governance and remained in breach of the legal regulation relating to good governance.

This service scored 61 (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 made progress since the last assessment in developing a shared vision, strategy and culture, with an increasing focus on openness, inclusion and person‑centred values. However, leaders had not yet fully embedded this approach to ensure people experienced the same quality of care regardless of which staff member supported them.

People told us care had become more consistent since the last assessment. However, some people said care could still feel less consistent when supported by staff who were less familiar with them. This showed improvement in culture and practice, while also indicating that consistency was not yet fully embedded.

Staff spoke positively about the culture within the service and described it as more open and supportive. Staff told us leaders encouraged communication, reflection and shared learning, which helped promote a more unified approach to care.

The manager described how they had actively worked to improve staff culture by promoting inclusion, openness and person‑centred care. Feedback from people and staff supported this approach and demonstrated progress in aligning staff practice with shared values.

Improved leadership at service level had strengthened engagement and culture, enabling more effective collaboration with the wider organisation. However, leadership instability meant these arrangements were not yet embedded or assured.

A new interim manager had been in post for approximately six weeks at the time of the assessment. Despite the short timeframe, people and staff spoke very positively about the manager’s approach and visibility. Staff described the manager as approachable, inclusive and compassionate, and people told us care had become more responsive and person‑centred.

The manager told us how they had focused on strengthening relationships, improving communication and enabling staff and representatives from the wider organisation to work together more effectively. Feedback from people and staff supported this, with examples of increased engagement, openness and shared problem‑solving.

We found that under previous management arrangements, the provider had maintained oversight and sought support from the wider organisation to assist with service improvement, including supporting the implementation of electronic care planning systems. However, staff told us they were not always involved in discussions or changes, and an individual from the wider organisation described feeling unable to engage meaningfully with the staff team or progress planned improvements at that time.

In contrast, the current interim manager actively facilitated engagement between staff and representatives from the wider organisation. Staff were made available, communication was open, and the individual providing support told us they felt listened to and able to implement changes effectively.

While staff were very positive about the current manager’s leadership and early improvements were evident, leadership and governance systems were not yet sufficiently embedded to assure sustained compliance with regulatory requirements.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

The provider had strengthened governance arrangements since the last assessment; however, systems were not yet operating consistently or effectively enough to ensure sustained compliance with legal requirements and safe care across all areas of the service. These shortfalls were evident in areas such as safer recruitment practices and elements of medicines management, where governance systems had not yet consistently assured compliance and oversight.

At the last assessment, governance systems did not consistently identify or address risks, performance and outcomes. At this assessment, we found some improvement and the provider was no longer in breach of 4 of the 7 legal regulations identified previously, demonstrating leaders had taken action to address several concerns and improve oversight.

However, governance systems were not yet fully effective or embedded. The provider remained in breach of 3 legal regulations, which indicated leaders had not consistently assured themselves that all risks were identified promptly, recorded accurately and mitigated effectively in practice. While leaders carried out audits and oversight activities, these had not yet consistently demonstrated improvement in outcomes across all areas. For example, audits and oversight arrangements did not consistently identify risks relating to medicines management and safer recruitment, which meant known issues were not always addressed or embedded in practice. This limited the provider’s ability to fully assure the sustainability of improvements and the ongoing safety of care.

Leaders had developed a comprehensive action plan to address the remaining governance shortfalls. The action plan included clear actions, responsible leads and defined timescales, and demonstrated leaders had a structured approach to quality improvement. We saw evidence leaders used this plan to track progress and prioritise areas of risk.

The provider had improved governance processes to support monitoring of care delivery, risk management and staff practice. Leaders demonstrated a stronger understanding of service‑level risks and responded more effectively to feedback, audits and assessment findings. This contributed to improvements seen across other quality statements.

Leaders showed commitment to improvement, engaged openly during the assessment and used the action plan to drive change. However, further time and evidence of impact were required at the time of assessment to demonstrate governance arrangements were fully embedded, effective and capable of sustaining compliance and continuous improvement.

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.

Leaders demonstrated a commitment to learning, improvement and innovation to drive better outcomes for people. This showed progress since the last assessment; however, learning systems were not yet fully embedded or consistently effective across all areas of the service.

At the last assessment, the provider had developed a detailed service improvement plan and demonstrated a clear intention to improve; however, leaders had not yet fully implemented or embedded all changes. At this assessment, we found progress.

Leaders continued to use a comprehensive action plan to guide improvement activity. The plan included clear actions, identified leads and defined timescales, demonstrating a structured approach to learning and quality improvement. We saw evidence leaders used this plan to review progress, respond to assessment feedback and prioritise areas of highest risk.

The provider promoted learning through a range of mechanisms, including sharing learning from incidents, audits and oversight activities. Leaders responded to feedback from assessments and monitoring by introducing changes to practice, training and systems. This contributed to improvements in areas such as safeguarding, monitoring of outcomes and person‑centred care.

However, learning systems were not yet fully effective or embedded. The provider remained in breach of three regulations, highlighting that learning had not yet resulted in sustained improvement across all areas.

While leaders demonstrated openness to feedback and a willingness to learn, further time and evidence of impact were required to demonstrate that learning, improvement and innovation were consistently driving safe, compliant and sustainable practice across the service.