Fornham House Residential 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 inspection we rated this key question good. At this inspection 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 82 (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 clear shared vision, strategy and culture, which was reflected through its policies and procedures. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

The management team had created an exceptional culture that was embedded across the service and clearly understood by staff, people and their relatives. The registered manager and deputy manager fostered a culture of honesty and open communication, which was consistently reflected in how staff worked together across the service. Staff told us they felt confident to speak openly with managers, share ideas, and raise concerns knowing these would be listened to and acted upon. This open and transparent approach not only supported strong and trusting working relationships, but actively encouraged continuous learning, reflection and improvement across the team.

The exceptional culture was further reinforced by leadership that was highly visible, accessible and engaged in the day‑to‑day life of the service. A relative said, “[Leaders] have a visible presence and clearly involve themselves with[people] and their families, rather than be shut away. I find them easy to approach and that they give me time. I am yet to be involved in a formal care plan review but feel that ongoing dialogue means that this is updated naturally rather than the need for an appointment.”

Leaders were consistently visible and approachable, maintaining regular contact with people using the service, their relatives and staff. This presence reinforced shared values and strengthened teamwork across the service. Staff described feeling genuinely supported and valued in their roles, and this was evident in the way they collaborated with one another and took collective responsibility for delivering high quality, person‑centred care. Many staff spoke positively about their work environment, describing a strong team spirit and a clear commitment to compassionate care.

Staff feedback consistently reflected the positive impact of leadership on morale and well-being. One member of staff told us, “I think we are a generally a happy team and that shows through to [people]. I think the managers always have their door open and are very approachable.” Another staff member said, “Managers are walking around but also have an open door policy. There are ‘mental health appointments’ with [registered manager] which are great and supportive. [Deputy manager] works weekends and late evenings and sees night staff at 6 o'clock in the morning. [Registered manager] is always visible.” A third staff member commented, “What can I say about [deputy manager] they are very hands on… I have never worked with a deputy that will lend a hand in every department.”

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. The leadership team were knowledgeable about people and their care needs and were able to answer any questions that we had. We observed warm and friendly interactions between leaders, people and staff.

The registered manager was experienced and had a strong understanding of their role, responsibilities and the relevant legal requirements, and worked proactively to ensure compliance. People and relatives told us the whole management team was approachable. A relative commented, “The management has been excellent.” Another relative said, “I looked at numerous care homes for my [family member]. Admittedly, some were smarter in terms of the building environment, but beneath the surface I had concerns about the skills and experiences of the staff… Of all the home managers I spoke to, [registered manager] was only one of two who offered to visit and assess my [family member] in person… [registered manager’s] attention to [family member] and interest in actually seeing [family member] and not their ‘behaviours and condition, gave me huge confidence. [Registered manager] treated [family member] with dignity and respect, clearly leading by example.”

Staff were also very complimentary about the registered manager, deputy manager and wider management team and the ethos of the whole service. Staff said they felt well supported.A staff member told us, “The managers are very visible on the floor. They help in the dining room most days. Serving the meals. They are often in the lounge talking with [people]. They keep up to date with medication rounds by doing them, themselves.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The registered manager actively promoted a positive and open “speaking up” culture within the home, where staff felt encouraged and supported to raise concerns, ideas or feedback. Everyone we spoke with told us they felt confident to speak up if they had any concerns and were reassured that these would be taken seriously and acted upon. Staff described managers as approachable and visible, which helped create an environment of trust and transparency.'The registered manager told us, “To ensure [people] diagnosed with dementia are empowered and enabled to have a voice, we designed dementia friendly feedback questionnaires to support them to express themselves in a manner that is most suitable to their needs.

A staff member commented, “I think we are a generally a happy team and that shows through to [people]. I think the managers always have their door open and are very approachable.” Another staff member told us, “I feel valued and appreciated every day.”

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 promoted an inclusive working environment where staff felt respected and supported.

The management team actively sought and considered staff feedback through a range of mechanisms, including quality surveys and team meetings. This helped ensure that leadership promoted an inclusive and fair culture across the service. There were no concerns raised regarding workforce equality, diversity and inclusion during the inspection.

The provider had clear responsibilities, roles, systems of accountability and overall good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

We discussed the concerns identified in relation to cleanliness and the general condition of the environment with the registered manager and senior leaders during the inspection. Leaders were open, transparent and receptive to feedback, and acknowledged the shortfalls we identified. They demonstrated a proactive and responsive approach, taking immediate action to address risks and improve standards both during the inspection and in the period immediately afterwards.

We saw that all soiled and stained furniture identified during the inspection was removed from use and appropriately disposed of, and carpets in affected areas were deep cleaned to reduce the risk of infection and improve the overall cleanliness of the environment. These actions helped to mitigate immediate risks to people living at the home and demonstrated leaders’ willingness to act promptly when concerns were raised.

The registered manager shared detailed plans outlining a wider programme of refurbishment and environmental improvements, aimed at addressing longer‑standing issues and ensuring the premises were safe, clean and well maintained on an ongoing basis. These plans included upgrading and redecorating key areas of the home and improving systems for monitoring environmental standards. This provided assurance that leaders were taking steps to strengthen governance arrangements and reduce the likelihood of similar issues recurring in the future. The registered manager told us, “Daily walk round documents have been changed to reflect checking of cleanliness, check of chairs in the lounges. Chairs in bedrooms has been added to ‘resident of the day’ check form.”

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.

People’s care and support plans demonstrated that they were referred to appropriate healthcare professionals in a timely way when their needs changed or when specialist input was required. This included referrals to GPs, district nurses, community mental health teams and other specialist services, depending on people’s individual health needs.

The provider worked in partnership with a range of stakeholders within the local community to support people’s care, well-being and quality of life. This included maintaining good working relationships with healthcare professionals and other relevant services to promote continuity of care and positive outcomes for people living at the service.

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. They actively contributed to safe, effective practice and research.

The leadership team placed an importance on learning, continuous improvement and innovation, proactively adopting new approaches to enhance safety, quality and outcomes; this included active involvement in a ‘decaf project’ led by Care England and partner organisations as part of a wider falls‑prevention strategy. There was also participation, in partnership with the Local Authority, in an assistive technology project to further reduce falls risk and promote independence.

There were also effective systems in place to learn from accidents and incidents, safeguarding concerns, complaints and situations where things had not gone as planned. Learning from these events was raised in daily leadership meetings and cascaded to staff through meetings and supervision. This collaborative and open approach helped drive and promote continual development across the service and shared learning from peoples lived experiences.