Fleetwood Heights

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.

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 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’s mission statement and values were displayed in the service.

Our observations and discussions with staff confirmed they were committed to delivering respectful and compassionate care. However, our discussions with people identified not everyone received care and support in a timely manner or had choice and control over their daily lives.

The provider did not consistently have skilled and inclusive leaders in place, who understood the context in which they delivered care, treatment and support or who embodied the culture and values of their workforce and organisation.

A manager was in post when the service re-opened in April 2025, but left a few weeks before this inspection. A new manager had recently taken up post, and recruitment for a deputy manager was ongoing. Changes in management had affected leadership stability and impacted on quality and continuity of care. However, staff spoke positively about the new manager, describing them as approachable and supportive, with an open-door policy. Senior management were also present on-site to provide additional support. People and relatives generally felt the service was well managed, although many were unaware of who the manager was. One relative commented how the home had a relaxed atmosphere and staff were welcoming during visits.

More time was required to embed the management changes and stabilise leadership at the service.

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

Management were visible in the service and operated an open-door policy for people, staff and relatives.

Staff were aware of the whistleblowing policy and felt any concerns they raised would be listened to and dealt with.

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 provider employed a diverse staff team including different ethnic backgrounds and genders. Staff meetings and supervisions showed staff were included in decision making.

Staff spoke of an inclusive culture where there was good teamwork and support for each other. Workforce well-being schemes and reasonable adjustments were available to employees.

The provider needed to demonstrate further embedding of responsibilities, roles, systems of accountability and good governance.

Since re-opening in April 2025, the provider has worked with the local authority and ICB to make improvements at the service. Governance processes were in place and effective in supporting some areas of service improvement. However, the clinical governance meeting on 15/10/25 identified audits were not consistently robust or completed on time. While audits identified issues and actions, these processes required further embedding.

Routine audits were being carried out, but shortfalls remained which could pose risks if not addressed before admitting new people to the service.For example, internal and external medicines audits identified similar issues to those we identified at the assessment, indicating improvements had not yet been fully implemented. More rigorous checks by trained and competent staff were needed to ensure documentation is accurate and complete. Staff deployment was not always effective in meeting people’s needs and giving them choice and control over their lives.

However, the provider and manager were committed to ongoing service development, which was demonstrated during the assessment process with timely responses to some of the concerns identified.Closing these governance gaps is essential to maintain regulatory compliance and ensure systems and processes effectively support the service as it grows.

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 had recently contacted some local communities and was looking to develop this further by establishing active links with community groups and organisations. The service supported people to engage with activities and events both inside and outside of the home, promoting social inclusion and enhancing their well-being.

Care records showed effective partnership working with a range of healthcare and social care professionals. The service continued to work with the local authority and integrated care board (ICB) to ensure improvements were implemented and sustained. This collaborative approach ensured people’s care was well coordinated and responsive to their changing needs.

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.

The provider’s service improvement plan identified improvements needed and showed actions taken in response. However, systems intended to support ongoing learning and improvement were not always effective as we identified shortfalls which had not been detected or addressed through the provider’s quality management processes. Some improvements were still being implemented and the provider was working towards addressing the outstanding concerns. We saw best practice information had been shared and disseminated across the wider provider group.