Foundation 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 Outstanding. At this assessment the rating has changed to 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 regulation in relation to good 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 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.

Staff and leaders consistently described a culture focused on supporting people to achieve their goals, maximise independence and live fulfilled lives. Values were visibly displayed within the service and were reflected in the way staff supported people.

There was a commitment to developing a positive and inclusive culture. Staff told us they felt supported by colleagues and leaders and described good teamwork across the service. One staff member told us, “I enjoy the good relationship we have with colleagues, the residents and management. What works well is the support staff have for each other.”

Leaders had actively supported staff through periods of workforce change and took steps to promote integration and inclusion. For example, following an increased recruitment of overseas staff, managers developed practical resources to support communication and deliberately mixed teams to encourage relationship building and prevent division. Leaders told us, “We have had a cultural shift in the recruitment and staffing, and new staff have settled really well” and “I was really conscious I didn’t want there to be a divide, we mix up staff working together and experience working with new people.”

The service sought feedback from people and used this to understand culture and engagement. Leaders described reviewing resident feedback, monitoring staff engagement and accessing an internal enrichment facilitator to help shape service development. A cultural enrichment training session had also been held with staff to identify strengths and areas for improvement. One staff member said, “I am giving back to society, caring passionately for the people that live here, it makes me fulfilled. Understanding different peoples and staff needs, able to support and assist people to achieve their goals. Each resident is unique and different, I am impressed when learning about people, how independent they have become, how they improve every day.”
 

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The provider did not always have effective oversight of areas requiring further development. This meant required improvements were not consistently recognised. We saw this in areas relating to the environment, people’s recorded information, medicines and incident reporting.

Quality monitoring tools were not always used effectively by leaders to drive the needed changes. We saw this meant that repeated areas of improvement previously identified had not always been addressed to improve the service environment and care people received.

Although leaders did not consistently demonstrate the skills required to critically assess service quality, they were well regarded by people and staff and had established positive relationships within the service. An open-door approach was promoted, and leaders maintained a regular presence within the home through handovers, supervisions and day-to-day support.

Staff consistently described leaders as approachable and supportive. Staff told us they felt listened to and that concerns would be acted upon where required. One staff member said they received "a lot of support" whilst others described leaders as approachable and responsive. Feedback from people and their relatives included, “[Interim manager] is brilliant” and “Yes, it's well managed."

Leaders demonstrated commitment to staff development. Leaders explained they would support staff to undertake additional learning and development where appropriate. Staff described receiving support from senior leaders and acknowledged the contributions of the acting leadership arrangements in maintaining service stability, whilst the registered manager was unavailable. Staff told us, “Management are really helpful and listen to me and are approachable”, “They are approachable and they listen.”

Opportunities were available for leaders to maintain their own skills and access further development prospects including internal and external training opportunities, qualifications and professional forums. One leader spoke about the support they received commenting, “We meet as long-term living teams and we can support each other and there are monthly face to face meetings.”

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

The provider promoted a culture where people, relatives and staff were encouraged to speak up and share concerns. Leaders demonstrated an open and transparent approach and described working proactively with people and families to address issues before they escalated into formal complaints.

Staff had access to policies and processes to support whistleblowing and were able to attend regular meetings where concerns and practice issues could be openly discussed. Records showed staff were encouraged to challenge and provide feedback. We saw recorded in supervision records reassurance from managers there were "no secrets within the management team" and staff were welcome to challenge any decisions.

People had opportunities to share their views through resident meetings, feedback surveys and day-to-day discussions with staff. Meeting records demonstrated people were consulted on matters affecting the service, including activities, communication systems and whole-home trips. Feedback from people and relatives indicated they knew how to raise concerns and felt complaints would be addressed appropriately. One leader told us, “If they [people] do have a concern we work through it before it becomes a complaint.”

Staff felt comfortable raising concerns with leaders. One staff member told us they were happy to speak up and report issues with leaders when needed. Staff feedback recorded in May 2026 identified improvements in communication and support for new staff.

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 given equal opportunities for recruitment, training, development, and promotion based on their skills and abilities. The service promoted an inclusive culture where everyone felt valued, listened to, and supported. Policies and procedures were in place to prevent discrimination, bullying, and harassment, helping to create a positive working environment. One staff member told us, “Staffing is good, we help each other, we have a good team. Teamwork here is amazing.”

The service promoted workforce equality by providing cultural awareness induction sessions for staff. These sessions helped employees understand and appreciate different cultures, backgrounds, beliefs, and experiences. Leaders informed us a culture training session was planned aimed to strengthen effective communication and cohesion among team members. By increasing awareness and understanding, the service aimed to create a more inclusive working environment where all employees felt valued, respected, and supported regardless of their background.

Following a growing number of overseas professionals joining the workforce, leaders had taken proactive action to put things in place to support them in providing care to people. One example shared was around a folder with lunchtime meal ideas and simple guidelines on how to prepare these meals to support unfamiliar cultural dietary requests. Plans were being discussed for staff members to introduce and prepare foods within their culture to share with people. One leader told us, “We want to create exposures to new experiences for people.”

Team meetings were held monthly and were delivered both face-to-face and virtually to ensure all staff had the opportunity to attend. Minutes were recorded and distributed following each meeting. The service also delivered themed handovers covering important topics such as fire safety, safeguarding, and the Mental Capacity Act. Staff were encouraged to actively participate in these sessions through discussions and question-and-answer activities, helping to reinforce knowledge, promote best practice, and ensure compliance with relevant policies and procedures.

The provider did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider did not have effective governance, management and oversight systems in place to consistently assess, monitor and improve the quality and safety of the service. Whilst there were a range of audits, quality reviews and monitoring processes in operation, these had not always identified concerns found during this assessment, limiting the provider's ability to take timely action and drive improvement. For example, an infection control audit undertaken in June 2026, stated all hazardous chemicals are kept behind locked doors, however this was not what we identified during our assessment.

We found inconsistencies between internal quality assurance findings and the evidence available at the time of inspection. An internal review in June 2026, had not identified concerns relating to allergy records, thickener requirements, environmental infection prevention and control issues, chemicals that were not securely stored, or notification requirements. In addition, management audits had also not identified inaccuracies in care records.

At the time of this assessment, call bell data was not being audited to ensure people received support in a timely way. During our assessment people raised concerns with us in respect of waiting times for call bells to be responded to. Leaders told us that a new system was due to be implemented which would address these concerns, however senior leaders told us they were unaware of the issues regarding the call bell system.

There was a process to report and investigate medicine errors and incidents and undertake regular audits of the management of medicines. However, these audits had failed to identify gaps in medicines management found during this assessment.

The provider operated a dual system of electronic and paper based records. This created a risk that concerns may not be consistently recorded or effectively monitored. We found discrepancies between paper based records and electronic record information around people’s health conditions.

The provider had not always submitted notifications to CQC in line with regulatory requirements. This related to incidents of potential abuse. There was a lack of understanding demonstrated within the leadership team of notifications that required notification.

Leaders were open and responsive when concerns were raised during the assessment, acknowledging areas requiring improvement and provided assurance action plans would be implemented. The provider had already started a review of compliance systems and planned to introduce revised governance arrangements, additional quality assurance processes and auditing of call bell data.

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 service recognised the value of effective partnerships in providing seamless support and ensuring people benefited from a coordinated approach to their care. Positive professional relationships had been made with local practitioners including pharmacy teams and doctors which encouraged open communication and proactive ways of working.

People were supported to develop meaningful community support networks, helping them build connections and maintain a sense of belonging within their local community. This included inviting in a local choir, supporting people to practise their chosen faiths and opening a provider charity shop in the community to connect with people. One person living at the service had been involved in the opening of this charity shop.

The provider fostered an inclusive environment where people could learn about and celebrate a variety of religious beliefs and traditions. The staff facilitated access to religious and spiritual support in line with people's preferences and beliefs. Staff told us they had reached out to local leaders of different faiths to ask if they would come and meet people in the service and share aspects of their religious beliefs and traditions. This gave people the opportunity to explore and learn about different practices, should this resonate with them.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

Whilst the service demonstrated commitment to advancing in some areas, further development was needed to support leaders in strengthening their approach to recognising and responding to areas requiring improvement. For example, in areas of quality monitoring for environmental concerns, incident reporting, medicines and risk management.

The provider promoted learning and innovation to enhance people's experiences and outcomes. Leaders demonstrated a willingness to listen to feedback and used this to drive change within the service. This included the refurbishment of the kitchen following people’s feedback to improve accessibility, independence and opportunities for people to participate in cooking activities.

The provider was developing new approaches to measuring progress, participation and independence, and the organisation had been recognised externally for its use of digital technology to improve outcomes for people. Innovation was embedded within the service through the use of assistive technology and collaborative projects. People were supported to use technology to increase independence, communication and participation. One person had contributed to workshops with technology developers to influence future assistive technology design.

The provider actively shared expertise with others and contributed to sector learning. Leaders had worked with specialist teams to develop training resources for education and care providers. Leaders spoke about how through collaboration training materials had been designed for schools and employees who assisted people with additional learning and support needs to better understand real life experiences of what was important to young people accessing these settings.

Plans were also in place for another provider to shadow staff and learn from practice within the service. This was to increase awareness of supporting people in a wheelchair and would involve observations of care practices and support from Foundation House staff. This partnership supports the exchange of knowledge and maintain consistent standards of care across services.