Fulford Care & Nursing 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 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 questiongood. At this assessment the rating has remained good. This meant people were supported and treated with dignity and respect; and involved as partners in their care.

The service was in breach of a legal regulation in relation to good governance. Governance systems and audits were not effective in identifying or addressing areas for improvement.

This service scored 68 (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 had a shared vision which embodied the culture and values of their workforce and organisation. The registered manager told us these values, and expectations of staff, were embedded through induction, team meetings, and supervision. Leaders were clear about how they expected care to be delivered and about the importance of learning from mistakes. They were open about areas they needed to improve and shared actions and learning across the organisation.

The provider and registered manager understood the context in which care was delivered. Leaders were inclusive and had a good understanding of the service and the people they supported. The registered manager had the skills, knowledge, and experience to lead effectively. They were visible during the inspection and demonstrated a clear understanding of risks and priorities for improvement. Feedback was positive, with one person describing them as “very pleasant” and a visitor stating they were “really approachable.”

The provider promoted a positive culture where people felt able to speak up and be heard. Staff understood the processes for raising concerns, including options to do so anonymously or with independent support, such as an advocate.

Staff were encouraged to share ideas and reflect on practice through team meetings and one-to-one supervision. Systems were in place for people, staff, and visitors to provide feedback on their experiences and raise concerns. Visitors told us they felt able to raise queries with the management team. One visitor said, “It’s good. Someone talks and people ask questions. No one is frightened to speak out.”

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. Staff uniqueness, diversity, and ethnicity were embraced within the team. Staff told us their individuality was supported by the organisation and were treated fairly. Relevant legislation and best practice guidance was implemented to ensure staff were treated in a fair and equitable manner. Recruitment processes supported fair employment opportunities.

The provider did not always operate effective governance systems or processes to ensure compliance with regulatory requirements. They failed to consistently act on the best available information about risk, performance and outcomes or share this appropriately.

Governance and quality monitoring processes were in place at both service and provider level; however, these were not effective and failed to identify the concerns found at inspection. This included significant gaps in the implementation of the Mental Capacity Act (MCA), the Oliver McGowan Code of Practice, and risk management processes. There was no evidence of harm or impact on people’s care and treatment however, these issues indicated governance processes were not always effective in identifying and addressing compliance shortfalls.

There was a failure to identify and submit required statutory notifications relating to safeguarding to CQC, which providers are legally required to do to enable regulatory oversight and follow-up action. Although safeguarding concerns had been appropriately managed through local authority procedures, this demonstrated a shortfall in governance and regulatory compliance.

Leaders recognised the challenges associated with operating a large, 74-bed nursing home. Business continuity plans were in place and covered key risks such as staffing pressures, adverse weather, and IT system failures to help ensure the service could continue to operate safely and effectively.

The provider did not always ensure effective partnership working to support seamless care for people. Information and learning were not consistently shared with partner agencies, and opportunities to collaborate for improvement were sometimes missed.

Feedback received before and during the inspection from partner agencies and stakeholders indicated that communication with leaders was not always conducive to effective partnership working. Members of the inspection team experienced inconsistencies in information provided by different staff members and were not always fully assured of the integrity of some responses to our requests. These concerns were addressed with the registered manager and senior leaders at the time.

People were supported to access routine healthcare and local community facilities, fostering inclusion, and wellbeing. The service was known and supported within the local community and had recently had an open day raising money for a local charity. A person said, they had an open day. They pulled out all the stops. They had stalls, a jazz band, and a raffle.’ People told us this had been very enjoyable.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome, and quality of life for people. They actively contributed to safe, effective practice and research.

The registered manager participated in local and national provider forums and networks and shared learning and good practice guidance. Staff told us they were encouraged to share their ideas for improvement and innovation. They understood their responsibility to be open in the event of anything going wrong and were supported to learn from any mistakes.