Fort Horsted Care Home Ltd

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 Requires Improvement. At this assessment the rating has remained 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 governance at 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 always have a clear shared vision, strategy and culture. They did not always understand the challenges and the needs of people.

The provider did not always have a clear, shared vision and culture that was consistently understood and embedded across the service. Leaders had spoken about values around dignity, openness and improvement, and these were visible from them in the service. However, these values were not always translated into consistent practice. For example, while leaders promoted openness about incidents and safeguarding, we identified delays in learning and analysis of incidents, with some not reviewed in a timely way or lessons not fully embedded. Staff described leaders as approachable and visible, and people and relatives experienced positive interactions and felt welcomed. A relative said, “They just give really good care they try their best.” However, inconsistent care planning, recording and follow‑through indicated that the shared direction was not yet fully embedded across all teams.

Leaders understood the context in which the provider delivered care, treatment and support. They embodied the culture and values of their workforce and organisation.

Leaders were visible, approachable, and compassionate in their interactions with people, relatives and staff. The registered manager was present in the service, supported staff on shifts and promoted an open‑door approach. A staff member said, “The manager has been doing wonderfully well, [they are] always ensuring the home is really good care, the residents are well taken care of. Most times I see [the manager] leave the office very late. [The manager] writes the care plan as well he is very good.” People knew the registered manager. A person said, “[Registered Manager] always says hello in the morning or when [they are] around.” People and relatives described positive relationships with senior staff and felt listened to when raising concerns.

The provider had taken steps to encourage staff to raise concerns and described a culture where speaking up was promoted. For example, speaking up was discussed in staff meetings. Staff told us they felt able to approach managers, including outside normal working hours, and leaders emphasised that raising concerns would not result in negative consequences.

People and relatives also felt comfortable sharing feedback and concerns, and many described prompt responses when issues were raised. A person told us, “I have no complaints, but I do I tell them and they sort it out. They are very helpful, if I say something has been wrong [Deputy Manager] will address it right away.” A relative said, “When [relative’s name] had an incident they did call me…they informed us and did all the necessary things.”

However, inspection findings showed that some staff were not always speaking up about some concerns in practice. We found safeguarding concerns, incidents and allegations were not always escalated or reported to management promptly. Escalation to external agencies was also sometimes delayed until after internal investigations were completed. This meant that although people felt able to speak up, systems to ensure staff raised concerns and that these concerns were consistently acted on without delay, were not fully effective. The provider implemented a system following the inspection to ensure possible safeguarding concerns would be escalated in a timely manner.

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.

Training records showed staff had completed equality and diversity training, and relatives felt their family members were treated with dignity and respect. Staff dynamics were monitored and action was taken, when necessary, by managers to ensure a supportive work environment. Staff told us they were supported with some reasonable adjustments, and long‑standing staff were recognised for their contribution.

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.

Governance systems were in place but were not always effective in identifying and mitigating risks in a timely way. The provider used audits, trackers, meetings and surveys to monitor quality and safety, including medicines, care planning, incidents and the environment. However, we found some gaps in the completion and oversight of audits, delays in analysing incidents, and inconsistent follow‑up of identified risks. Examples included some incomplete or inaccurate care plans and records of daily care as well as delayed review of incidents. This demonstrated that governance and oversight were not always robust or effective.

While leaders demonstrated commitment to inclusive care, including support for people’s identity and preferences, these approaches were not always consistently reflected in care records. As a result, leadership was not yet fully effective in ensuring consistently safe, high‑quality care.

Leaders had also not always met their requirement to notify CQC of important events. The registered manager acted following the inspection to notify CQC retrospectively and has since been proactive in notifying when required.

A health and social care professional told us, “Information sharing is generally effective, although there may be scope to improve consistency in documentation or timeliness in some cases.”

While leaders were able to describe actions that had been taken to improve the service, these were not always evidenced or embedded at the time of inspection. As a result, governance arrangements did not always ensure consistent oversight and sustainability of safe care. The provider introduced a weekly check which focused on different areas for review and improvement each day of the week to address the areas of concern we fedback about during the inspection. We will check this at our next inspection.

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 provider worked effectively with external partners to support people’s health and wellbeing. People had access to a range of health and social care professionals, including GPs, nurses, therapists and specialist services, and records showed regular involvement from these professionals.

The service also engaged with community resources, such as faith leaders and visiting groups, to support people’s social and spiritual needs. The service had links with the local community for example with a local schools and college where pupils came to the home and engaged with the people who lived there. Outside entertainers were also invited into the home to provide a range of activities for people to engage in. These partnerships helped promote continuity of care and positive outcomes for people.

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 and registered manager had made some improvement to the service including the home environment and had been addressing some areas of staff practice. Leaders described using incidents and feedback to identify learning, and there was evidence of some actions taken following concerns, such as environmental improvements and staff discussions.

However, processes to support learning and improvement had not always led to sustained improvement and changes in practice had not always been embedded. We identified examples where incidents, medicines errors and care issues had occurred, but analysis, action plans or reassessment of staff competence were incomplete or delayed. This limited the provider’s ability to demonstrate sustained improvement and innovation across the service. The provider told us actions they planned to take following the inspection to address the issues we raised during the inspection. They had created a new weekly audit to daily address different key areas of feedback from the inspection to ensure management made progress to improve the service in all areas required.