Frank Care Devon

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 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 service was in breach of legal regulation in relation to governance.

This service scored 39 (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 which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The provider talked about providing a service to many different client groups with significantly different needs without clarity about the needs of each group and the staffing skills and organisational ability that would be required to meet these peoples' needs. There was limited vision or strategy for staff to understand and support.

The culture in the staff team was poor. We heard from staff there was a poor approach from managers in the service who continued to inconsistently manage the delivery of pay, contractual agreements and relationships with their staff. The registered manager had imposed a direct and at times threatening style of management towards the staff. This poor culture impacted on the morale of staff and the quality of delivery in the service.

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

The registered manager was also the provider of the service. Therefore, they were fully responsible for the carrying on of this service. During this assessment we heard from staff about the poor practice of the management towards care staff. We heard of frequent underpayment and repeated late payment of salaries, imposition without agreement of unreasonable working hours and rostering and threats to staff of loss of their work visa or loss of employment if they complained about these employment practices. We also heard these practices were continuing. These practices had led to a poor working culture for staff and the significant loss of staff from the service, which was damaging to the quality of support received by people. One person said, “No, it’s not well led. It could be better. Carers are not treated well and the good ones are leaving. Communications could improve.”

When the registered manager was absent from the service, they were not leaving the service in the hands of a confident and appropriate member of staff. The staff member the registered manager had left in charge did not feel confident to begin this assessment in their absence. We carried out our visit as planned on 29 May 2026 but the staff member left in charge was unable to find the information required about the service and its systems.

People did not feel they could speak up and their voice would not be heard.

Leaders of the service did not act with openness, honesty and transparency. The service leaders had not responded to the concerns of care staff. The Home Office investigation led to the loss of the provider’s Sponsorship Licence. We heard the provider’s response to staff concerns had not changed since the loss of the Sponsorship License in February 2026.

Leaders did not encourage staff to raise concerns. Staff were not confident their voices would be heard. There was a culture which actively tried to dissuade staff from speaking up to raise concerns and those who did speak up were fearful as a result. For example, we heard staff had been threatened with dismissal, or visa cancellation which would lead to their deportation from the UK.

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.

Service leaders were not taking action to improve the experience of staff.

Service leaders did not prevent and address bullying and harassment in the service. For example, service leaders at times communicated with staff in a threatening manner.

Staff were of different ethnicities, nationalities, ages, gender, and experience which demonstrated diversity in the service’s staff team. Staff told us they worked well as a care team in the delivery of care during visits to people and did what they could to help each other.

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.

The governance of the service had not identified the failures in the quality of the service. Though there were some audits being carried out these had failed to identify or address the issues we found during this assessment. These failings in governance systems and processes meant people were not getting the quality of service they deserved.

Governance and oversight by the provider had not identified the poor culture that had developed between the service’s management, the care staff, and other stakeholders.

During the assessment from 28 April to 18 May 2026, the treatment of care staff by the service was found to be poor. The management approach of the service led to a substantial loss of staff from the service, and in a reduction in staff morale. This had caused a significant decline in the quality of service received by people due to; the loss of experienced and trained staff, the loss of staffing continuity, and the severe and frequent late arrival of care staff for visits to people.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The registered manager had not fostered good working relationships with system stakeholders. They had not met with the commissioning local authority for arranged meetings and were often difficult to contact.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider had an annual system of sending surveys to people, relatives and staff to gain feedback on the service. Responses were collated quickly. However, this annual review had not taken place as planned earlier in the year due to the challenges being experienced by the service. Therefore, there was no opportunity given to people, relatives and staff to comment on the quality of the service in 2026 or give views on how it could be improved.

The service did not have a vision, strategy or plan to overcome the challenges faced by the service.