Christ the King, Footherley Hall

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 in breach of legal regulation in relation to governance at the service.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager demonstrated a commitment and desire to provide high-quality care and was viewed by staff as approachable and supportive. However, the scheme of delegation in place was not operating effectively, which limited the manager’s ability to embed this vision across the service.

Communication between different tiers of leadership was inconsistent, and this breakdown did not support a transparent culture. As a result, the provider’s values were not always reinforced or reflected in day-to-day practice.

The registered manager and wider management team were keen to deliver care that reflected integrity, openness, and a person-centred approach. Staff spoke positively about the registered manager’s visibility and leadership, describing them as approachable and supportive.

However, the systems and processes in place to support communication and accountability across the management structure were not always effective. This limited the team’s ability to consistently embed the values and expectations set by leadership team and impacted the service’s capacity to ensure consistently positive outcomes for people.

The systems needed reviewing and strengthening to ensure the consistent delivery of high-quality, well-coordinated care and support. We fed this back to the registered manager who had begun to put in plans to make effective changes.

Staff told us there was a positive culture within the service that encouraged openness and transparency. They felt confident to speak up about concerns, ideas, or issues and believed their voices were heard and respected.

The registered manager described a range of support mechanisms in place to promote equality, diversity, and inclusion within the workforce. These included policies and procedures designed to protect staff with protected characteristics, as well as access to training and guidance to raise awareness and understanding. The provider aimed to foster an inclusive working environment where all staff felt respected, valued, and supported in their roles.

The provider did not have consistently effective systems of governance, accountability, and oversight in place. Roles and responsibilities were not always clearly defined or followed through, which impacted the service’s ability to monitor and improve performance.

Audits were either not fully completed or, when they were, could not be reliably used to drive improvement, as the information within care records was not consistently updated. This meant audit outcomes did not always reflect the actual quality of care being delivered. Additionally, there were discrepancies in how incidents were investigated and followed up, including gaps in assessing staff competencies and arranging additional training where needed. This impacted the provider’s ability to effectively monitor the safety and quality of the service, limiting their capacity to identify issues and drive meaningful improvements.

There was not always a proactive and positive culture of safety.

Practices around incident and event reporting were inconsistent across the service. Some staff did not always report concerns in line with policy or best practice. This meant that management were not always aware of incidents that had occurred within the home and were therefore unable to investigate or respond appropriately. The lack of oversight and follow-up limited opportunities for shared learning and improvement, ultimately impacting the development of a positive and open learning culture.

The management team did not always consistently promote a culture of continuous learning, innovation, and improvement across the organisation and wider system.

Opportunities to deliver improved outcomes, and quality of life for people were not always encouraged or embedded in practice. This was largely due to processes that were not seamless or consistently effective, particularly in relation to communication. Staff were not always clear on the systems in place, and managers lacked the oversight needed to drive and sustain improvement. These challenges made it difficult to embed learning and deliver meaningful change.

However, the registered manager was receptive to the findings of the inspection, acknowledged the areas requiring development, and had already begun taking steps to implement positive changes aimed at improving outcomes for people.