Frindsbury Hall 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 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 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 to 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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.
People and relatives consistently described the service as caring and supportive. Relatives expressed confidence in the environment, with comments indicating they had “No worries” and that their family members were well cared for. This reflected a culture focused on people’s wellbeing and day-to-day experience.
Staff also described a supportive and inclusive working culture. One member of staff referred to the service as “Like a family,” and others spoke positively about teamwork and supporting residents in a personalised way. Staff described working collaboratively and supporting each other during shifts to ensure people’s needs were met.
 

Leaders within the service were visible, approachable and supportive; however, leadership was not consistently effective in ensuring high-quality care was delivered across the service.
People and relatives knew who the manager was and described them as approachable and responsive. Staff also spoke positively about local management support and said they felt able to raise concerns and seek guidance when needed. This demonstrated that leaders within the home were compassionate and supportive in enabling staff to carry out their roles.
Staff described a positive team culture and told us they worked well together to support people. Observations during the inspection showed respectful interactions between staff and people, and a calm and organised environment.
However, although staff felt supported on a day-to-day basis, good leadership had not extended into consistently ensuring that good practice was embedded across all areas of the service. Findings during the inspection identified variations in care delivery, monitoring and consistency of practice.
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.
Staff consistently reported that they felt able to raise issues. They described speaking to managers about concerns and using supervision or informal discussions to highlight any problems or challenges.
Staff also described a culture where concerns could be raised during daily interactions, including handovers and team discussions. This demonstrated that speaking up was supported in practice.
Relatives also felt able to raise concerns, with feedback showing they would approach staff or management if needed.
Overall, there was an open culture where people felt able to speak up, although the effectiveness of follow-up actions was variable.
 

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 described a positive team culture where people supported each other regardless of role. Comments such as “we all pitch in” demonstrated a team-based approach and indicated that staff worked flexibly to meet people’s needs.
There was no evidence during the inspection of discriminatory practice or unfair treatment of staff or people using the service. Staff described feeling supported and valued within the team.
The service also supported people’s diversity and individual needs in practice, for example through adapting activities and recognising personal preferences.
 

The provider did not have effective governance systems to ensure consistent oversight, accountability and high-quality care.
Systems for monitoring quality and safety were in place, including audits and team meetings; however, these were not effective in identifying, addressing or embedding improvements in practice. Issues identified through audits, including concerns relating to care planning, documentation and risk management, remained evident at the time of inspection.
This demonstrated actions had not been effectively implemented, sustained or monitored.
Provider audits and development plans had identified a range of concerns across the service; however, these had not been fully addressed. For example, audits had highlighted gaps in care planning, including care plans not being updated to reflect changes in people’s needs. Monitoring and recording systems also showed gaps, errors within medication records. In addition, some audits lacked sufficient detail to clearly demonstrate what had been reviewed or how actions would be followed up. Despite these issues being identified, similar concerns were still evident at the time of inspection.
Records were not consistently accurate, complete or aligned. Risks identified within the service, including concerns relating to nutrition, equipment and care delivery, had been discussed at meetings. However, these did not consistently result in timely or effective action, and interim measures were not always put in place to reduce risk.
Care was not always provided in line with identified risks, and monitoring systems were not consistently used to identify and prevent deterioration or drive improvements. There was limited evidence that monitoring systems were used effectively to evaluate outcomes or support improvement over time. Although incidents and concerns were recorded, oversight systems did not ensure these were consistently analysed, reviewed or used to improve practice.
Overall, this meant the provider did not have effective oversight or control of the service. They could not demonstrate that risks were consistently identified, monitored and managed, or that improvements were embedded and sustained. As a result, they could not be assured that care was safe, effective or consistently of a high quality at all times.
 

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.
There was evidence of effective collaboration with healthcare professionals, including district nurses and other services. Staff described referring people appropriately when concerns arose and involving professionals in care where needed.
Relatives confirmed that staff communicated with them and sought external support when people became unwell.
The service also involved families in care, particularly for people with complex or changing needs. Relatives visited regularly and were part of ongoing discussions about care and support
 

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.
Systems such as incident reporting, audits and staff discussions were in place; however, these were not consistently effective in driving improvement. Issues identified through audits and monitoring processes remained evident at the time of inspection, demonstrating that learning had not been embedded into practice. Processes to support learning from incidents were not sufficiently developed. While incidents were recorded, associated “lessons learned” lacked detail and did not clearly demonstrate what had changed or how improvements had been sustained. There was limited evidence that themes were analysed or that learning was consistently shared across the service. Staff feedback highlighted gaps in understanding of systems, including uncertainty about monitoring tools and documentation processes. This indicated that learning was not consistently communicated, reinforced or embedded. Although staff adapted care based on experience and knowledge of individuals, this reliance on informal learning limited the provider’s ability to deliver consistent and measurable improvements. There was also limited evidence of innovation or proactive system development to improve care delivery. Overall, the provider did not have effective systems to support continuous learning and improvement. As a result, opportunities to improve care quality and prevent recurrence of issues were not consistently identified, implemented or sustained.