Fixby Healthcare Ltd

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.

This is the first assessment for this registered service. This key question has been rated 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 service was in breach of legal regulation in relation to 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 did not have a clear shared vision, strategy and culture. We found systematic failings in the management of the service, which meant the provider did not facilitate an effective learning culture.

The provider told us about their shared direction which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. Within the statement of purpose it stated, we ensure that each client’s needs and values are respected in matters of religion, culture, race or ethnic origin, sexuality and sexual orientation, political affiliation, marital status, parenthood and disabilities or impairments. When speaking with the registered manager they told us, “We value our client’s decisions and their families. We value any reviews or feedback from people. We value fair culture and openness. We value open reporting and being open and honest. We learn from our mistakes and have open communication. We take accountability of our actions. We want a good working morale.”

We found systematic failings in the management of the service, which meant the provider did not facilitate an effective learning culture. For example, we found issues relating to risk assessments, mental capacity assessments, medication records and staff training which had not been identified by the provider.

Staff listened to concerns about safety and investigated and reported safety events. Following incident and accidents actions were taken. For example, the registered manager identified a medication error and carried out a supervision with the staff member and provided further medication training to prevent future incidents.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. One relative told us, “Any questions asked were answered straight away.” The registered manager said, “We don’t disclose what people have told us, but we try to make sure we reduce or eliminate what has happened. We try to protect clients and staff. We encourage people to whistle blow. We want a culture of openness, and we don’t ever blame anyone. We learn and develop from this.”

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 registered manager told us, “We employ people because they meet the criteria we need. We don’t discriminate against race, gender or disability. We do our recruitment process fairly.”

The provider did not always have clear systems of good governance. For example, essential audit systems to monitor safety and quality were not always in place. There were medicine and care plan checks however, these were not audits to show where improvements could be made. Medicine checks were also not consistent, for example the last check completed on a person’s medication records was in February 2025. There were no other audits provided to us throughout the assessment to show how the service was being monitored. Shortfalls we found on assessment had not always been identified for example, issues relating to risk assessments, mental capacity assessments and medication records had not been picked up through robust governance systems.

Although we found no evidence of harm, this was a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff and leaders understood their roles and legal requirements.

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. One person told us their relative’s mobility had declined, and the service supported them to get an assessment for new equipment they needed.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research. For example, staff did not always receive their training in a timely manner to ensure safe care. Robust audits were not in place to show oversight and continuous learning.

Feedback from people and their relatives were sought through regular contact, surveys and reviews to drive service improvements. We found feedback from people and their relatives was positive.