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

The provider was previously in breach of the legal regulation in relation to good governance. Improvements were found at this assessment, and the provider was no longer in breach of this regulation.
 

This service scored 75 (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. The provider’s website emphasised treating people with dignity and as individuals, involving them in decisions and encouraging them to maintain their independence.

At our last inspection, the staff team felt they faced challenges and several expressed dissatisfaction at that time. At this inspection, we found positive changes had been made. For example, significant changes to the staff team, new systems and ways of working and improved communication. The registered manager told us the whole team had worked hard to make the changes and improvements and they were proud of what had been achieved. They believed people received a good standard of care and quality of life and staff were well equipped and supported in their roles.

Staff were proud to work at Frenchay House, and they were keen to provide high quality care. A staff member told us, “I’m passionate. I am happy working here. We need to remain as we are and continue to do a good job, but always aspire for more.”

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.

The registered manager was experienced and had the skills, knowledge, experience and credibility to lead effectively. They were clear with staff about changes, shortfalls or improvements which were needed and worked with staff to manage these. Staff said they felt well supported. One staff member told us, “The managers are both really supportive. They have been so positive. They are good. I learn from them. They are role models.”

Some people and their relatives were unsure who the managers were, or did not know them well. However, others told us they management team was approachable and they could speak with them if they needed.

The registered manager understood their responsibilities and notified the local authority and CQC of incidents or concerns as required.

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

Staff were able to speak up if they had concerns and told us they could talk to the registered manager or deputy. One staff member said, “Their door is always open. I have no anxiety about approaching them.”

Systems were in place for people to speak up and raise concerns or make suggestions. This included surveys, feedback cards, keyworker meetings and informal contact with staff and managers. Feedback from a previous survey carried out with people who lived at the service was positive. Resident meeting minutes showed people were asked for their views and information was shared about topics including activities, food, safety and quality of care. Relatives told us they would be happy to raise concerns and felt they would be taken seriously.

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.

Staff were positive about their colleagues and the team was diverse, made up of individuals from a wide range of backgrounds, ages and experience. One staff member said, “The team is marvellous. It has blended really well. The old and the new staff work together and help each other.”

The provider regularly hosted themed days which focused on different cultures. For example, during our inspection there was a celebration of Swiss food and culture, and we saw information about the recent Spanish and Italian days. To continue this theme and involve staff more, the provider was planning a Zimbabwean day and was inviting staff to join the professional chefs in preparing food for the homes.

The provider had policies and procedures in place regarding equality, diversity and inclusion and staff had received relevant training.

The provider had clear responsibilities, roles, systems of accountability and 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.

The management team carried out regular audits and checks to help make sure standards were consistently met and people were safe. Audits included medication management, care records, safeguarding and checks of the premises. Action plans highlighted areas for improvement and these were monitored to ensure timely follow-up.

Staff told us they felt the service was well run and understood their responsibilities in keeping people safe and providing them with effective, person-centred care. People and relatives also said the service was well led.

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.

Staff referred people to other professionals when needed. For example, district nurses, speech and language therapists and occupational therapists. Professionals told us they had good relationships with the service and found them to be responsive.

Some people were able to access the local community to visit pubs, libraries and shops. People were keen to be able to go on day trips because the weather was improving. Staff told us this could be arranged and transport was available to take people out.

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 team had made improvements to the service since our last inspection. The registered manager was open during the inspection and listened to feedback to continue to improve and develop the service.

Systems and processes helped ensure lessons were learned and action was taken to make improvements where necessary. Staff said incidents and learning were discussed during handovers, team meetings and individual supervision. This helped ensure they remained up to date and changes were made to continue providing safe and effective care.

The provider was actively involved in local and national networks and groups which shared knowledge and promoted improvement and innovation. This helped ensure ongoing development and embed evidence-based practice.