The Firs Care Home

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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last inspection we rated this key question good. At this inspection the rating had 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 provider was in breach of legal regulation in relation to the governance of 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 did not have a clear shared vision, strategy and culture. The provider informed us they had instructed staff via staff meetings about safe ways of working. Following our last inspection, management had taken action to inform staff not to prop fire doors open and not to take windows off restrictors. In the providers action plan it stated ‘All prompts (props) have been removed and all staff have been notified to ensure that no doors are prompted (propped) open with any furniture or objects’. When we carried out the site visit for this inspection, staff were not following safe ways of working and had doors propped open around the service. This did not demonstrate a culture and understanding of providing safe care to people at all times. One person had been given a door wedge to unsafely keep their door open. Staff were not able to tell us where the door wedge came from, but this was not providing safe care as expected by the provider.

Not all leaders understood the context in which the provider delivered care, treatment and support. Since the last inspection there had been a change in day-to-day management at the service. Whilst there was a registered manager in post, they were not working at the service full time. They told us they visited the service every week, but people and staff told us they did not see the registered manager for long periods of time, sometimes a month or longer. A new manager had been employed to carry out daily management duties. Although feedback about them was very positive they were unsure of the legal framework for management of care homes. We found incorrect advice had been given to the new manager about CQC notifications by the provider. Due to their lack of knowledge, the new manager had followed this incorrect advice. This meant statutory notifications had not been submitted to CQC as required by law.

Staff did not always feel they could speak up and that their voice would be heard. The provider had a whistleblowing policy but it was not effective in making sure all staff felt able to speak up. Staff told us they had not felt able to raise concerns about the previous manager. Staff did not feel they would be heard and were not comfortable sharing their feedback. Prior to this inspection changes had been made to the management team. Staff told us this was a positive change, however, this change needed time to embed into daily culture. One member of staff said, “It is a totally different atmosphere, management change has made the difference, they are now listening.”

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 had a range of policies to promote equality, diversity and inclusion. Staff told us they had not observed any discrimination and all staff were welcomed at the service. One member of staff said, “I have not seen any discrimination, everyone is treated kindly. We have people who live here from other countries, they are included, I don’t feel I see discrimination, everyone is welcoming.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Governance systems were not effective in assessing, monitoring and improving the quality and safety at the service. We found audits and checks had been completed but had not identified shortfalls in ways of working. For example, safeguarding audits completed in December 2024 identified all CQC notifications had been submitted as required. However, we found a number of notifications that had not been submitted. In the provider action plan received after the last inspection, the provider informed us they were going to complete monthly health and safety checks for all window restrictors. This action had not been completed. The provider had completed 2 out of hours visits to check how staff were working when management were not in the building. Records seen for those visits did not include a check of doors being propped open or that windows were safely on the restrictors.

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. Staff told us they had good working relationships with visiting healthcare professionals. One member of staff said, “We have a good relationship with the surgery and nurses, I think it is important.” Healthcare professionals shared positive feedback about the service and the approach of the staff teams. Comments from professionals included, “If there are any concerns of the residents the senior staff will inform us. Excellent home, no issues with any of the staff” and “I think the Firs is a lovely home where staff really care about the residents. They give it a homely feel.”

Staff were keen to learn and try new ways of working. Staff told us about an initiative with the local authority they were engaging with. The initiative was a weekly exercise and games session which aimed to improve people’s mobility. Staff were being trained to continue with this initiative once the local authority participation stopped. Staff told us they had opportunities to learn and reflect with the new manager. Staff now felt involved in discussions about events that had happened and what could be done to make improvements. The provider was reviewing use of electronic care planning systems to improve record keeping.