Walfinch Reigate & Horsham

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• 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 newly 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 provider was in breach of the legal regulation in relation to governance at the service.

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 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 managing director had a clear vision and ethos of the service he wanted to deliver. He told us, “As part of the interview, I like to meet potential staff before we decide that we go ahead with them and ensure they are the right fit. They don’t necessarily have to have the experience, but they need to have the core prerequisite of that they’re a nice caring person. We make sure they tick the boxes. We tell them there are care services out there that do the bare minimum but we want to go above and beyond.” Staff we spoke to echoed this. One staff member told us, “Walfinch is one of the best agencies I have worked for, they know their staff and clients as individuals and ask about how us and our families are.”

Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

There had been a recent change of leadership at the service. The registered manager had left the service with immediate effect the week before our assessment, and the managing director was overseeing the service until a new registered manager was successfully recruited.

We identified several concerns regarding the effectiveness of the service’s quality governance systems. The managing director and compliance manager had not consistently exercised oversight to ensure these systems were functioning effectively or being used appropriately. As a result, there was a continuing risk that leaders might lack the necessary skills or insight to manage the service safely and maintain high standards of care.

There was mixed feedback from staff about the support from the management team. When we asked one staff member if they felt supported, they said, “Not at all - I have had very little interaction with anyone from the office since joining Walfinch.” However, another staff member told us, “I am supported.”

Staff did not always feel they could speak up and that their voice would be heard.

Staff told us they did not always feel that action would be taken should they raise concerns. One staff member said, “You can raise concerns, but they are not always dealt with.” Another staff member said, “I have noticed things that have changed and needs to be updated in the care plan and I notify the [management team in the] office but no changes are made.” However, a further staff member told us, “I have never felt that I couldn't offer feedback, even if not specifically asked.” The managing director told us, “We appreciate some staff members feel safer coming forward than not, so during spot checks we ask if they have any concerns with anything.”

The provider’s whistleblowing policy was available on their electronic monitoring system and was on display within the office. This meant staff were able to access information on how to speak up when they needed to.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

We received mixed feedback from staff on the equality of the service. One staff member said, “I believe staff are treated equally.” However, another staff member told us, “On sponsorship you don’t get listened to. I see people who are not on sponsorship are treated differently and better.” We did not find any evidence to confirm this.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Care and governance records were indistinct and lacked detail. We observed that management meetings had been occurring monthly. Within these areas, such as rotas, compliance and training were discussed. However, no actions from the meeting were recorded, so areas for improvement could not be followed up on at the next meeting. This meant opportunities were missed to improve areas of the service due to poor governance records. Furthermore, one person whose care plan did not contain information about their fluctuating mobility needs had experienced a fall. Therefore, inaccurate or vague care plans may have contributed to this incident, leaving the person at risk of further falls.

Although the managing director had invested in new systems to support the running of the service, there had been no governance oversight to ensure safe and quality care was being delivered, nor to ensure documentation was up to date and thorough. For example. although the managing director and compliance manager told us they had had concerns around the previous registered manager’s governance skills, formal governance systems were not introduced until the week of our assessment. The compliance manager told us, “[The managing director] and I have started to work on a quality plan. We’re looking at things like how many staff and clients we have, lengths of care calls, any safeguarding concerns. The way it was run isn’t where it is now. But that’s in its infancy.” We reviewed the quality plan, which was started on 21 November 2025. Improvement actions on the plan did not name people responsible for ensuring tasks were completed, nor did they record when any actions were due. This meant, it was not effective.

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.

The managing director told us, “We work closely with a village hall for our Thrive groups. We communicate closely with the district nurses.” The provider also worked closely with the integrated care board (ICB) when supporting people who received funding from them.

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 the development of safe and effective practices and research.

People and their relatives were given various opportunities to provide feedback on the service. The compliance manager told us, “Client feedback is requested at point of review, they are done nationally annually.” The managing director added, “We encourage them to give feedback as and when though, we want to know about any concerns straight away.” People we spoke to told us of situations where they had requested certain staff members no longer attend care calls for them. They confirmed this had been listened to and their wishes acted upon.