Friary 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 good. At this assessment the rating has changed to Inadequate.

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

This service scored 36 (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 always 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.

Staff did not receive regular supervisions or team meetings to ensure there was a shared vision and strategy that was understood and modelled by staff and the management team. We found no evidence that shared strategy, culture and values were embedded within the team.

Feedback from staff members indicated a lack of understanding of roles and responsibilities, shared vision and blurred responsibilities. The registered manager told us, “I promote a culture that is person centred, open and inclusive in several ways. I leave my office door open as much as possible so that staff and residents feel that they can come and talk to me when they feel they need too. I also try to see all the residents at least twice a week, engage in conversation with them and support them with activities of daily living so that I am having an active role in their care at Friary House.”

A staff member told us, “We have regular supervisions with our manager and there is an open-door policy so we can go to our manager whenever we need to for support.” Our inspection found there had been few supervisions carried out with staff. Another staff member told us “we don't have senior members of staff at friary we have the care assistants… we like to think we are all equal and are happy to support each other when needed”. However, another staff member told us more delegation on shift would be beneficial.

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.

The registered manager did not understand their role and responsibility around recruitment in line with Schedule 3. The registered manager was unable to effectively utilise the electronic recording system in place which impacted on their ability to monitor and maintain oversight of the service. Areas which required improvements to ensure safety and quality across the service were not noted as a result.

The service did not maintain accurate, complete and contemporaneous records for each person that included a record of the care and treatment provided and of decisions taken about care provided. In addition, not all records were available during the inspection due to a lack of an effective filing system. Records were hard to locate and not readily available for inspection. We requested records multiple times and the registered manager took a significant time to locate them. For example, accident and incident forms and SALT assessments were not immediately available in people’s records which could result in inappropriate care delivery.

We asked staff to provide feedback about the registered manager of Friary House. One staffmember told us “they are very approachable and will do anything they can to support and correct things. The registered manager has always been very friendly welcoming and extremely supportive, [they are] a manager who will go above and beyond to support the team and residents”.

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

The provider had not sought feedback from staff, for example, though a staff survey or an online anonymous questionnaire to enable their views to be expressed freely.

Staff members were not able to provide feedback anonymously. For example, a staff member told us that staffing levels were not always adequate. This indicated more work was needed to ensure feedback could be shared freely by staff without fear of repercussion.

When we began our inspection there was no freedom to speak up policy. The provider added one during our inspection site visits. This meant that staff had not been informed as to how to speak up or the process to follow if they were not happy. Some staff members relied solely on the positive relationship with the registered manager which enabled them to discuss concerns.

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.

The training matrix showed that not all staff had completed training in diversity, equality and inclusion in line with best practice.

A staff member told us, “[Registered manager] is the head of our team and has always been there for us, she supports us at work and if needed personally as well. [They are] always willing to listen to us regarding any problems we have and will work through them with us.”

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

The provider did not monitor the quality and safety of the service or ensure staff were competent in their roles. For example, they did not complete competency checks of staff’s abilities in medicines administration or moving and assisting. This meant that they could not be assured whether staff had completed training and developed skills to safely support people. The provider did not have effective systems and processes in place to ensure oversight of policies being received and understood by staff. This placed people at risk of harm.

The provider did not establish and operate systems to monitor and improve the safety and quality of care provision. For example, multiple audits undertaken were ineffective and had not identified the shortfalls found during our inspection. For example, systems and processes for auditing medicines did not identify or address concerns with medicines administration and recording found during our assessment.

The service did not maintain an accurate and complete record of safeguarding concerns, investigations and outcomes. There was no system in place to enable management to have oversight of safeguarding. Safeguarding incidents reported were stored in people’s paper files, and safeguarding audits were not completed. This meant the service was not able to identify any trends or themes or receive appropriate external challenge and scrutiny to help support and drive learning within the service.

An improvement plan did not show that the provider monitored their progress against their plans to improve the quality and safety of services. They did not take appropriate action where progress was not achieved as expected. Systems and processes to identify where quality and safety were compromised were not always effective and did not support an appropriate response without delay.

All of these issues contributed to the registered manager not having clear oversight of quality and risk in the service which contributed to people being at risk of avoidable harm.

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.

People and their relatives told us that the service would contact healthcare professionals required. A professional told us, “Staff are happy and comfortable to raise well-being concerns {about people}.” However, we found inconsistencies in referrals made. For example, a referral for contractures was not made however community nurses were working with Friary House to support people with other conditions.

The provider did not always focus on continual 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.

Staff told us that they felt supported by the management and had supervisions, however we saw these were not regular. There was no ‘lessons learned’ process in place. The service improvement plan did not include actions identified from all sources, such as the fire risk assessment, maintenance work in a person’s bedroom and feedback from staff during supervision.

The service improvement plan had identified staff supervision should be completed every 3 months. However, we did not see evidence that staff received regular supervision. This placed peoples’ and staffs’ health and well-being at risk of their needs not being met and did not afford the manager oversight to make the required improvements.

Staff, people and relatives generally felt that they could speak to the management. However, we found no evidence that they we actively encouraged to do so.