Fitzwilliam Lodge

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 outstanding.

This service scored 89 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities. Fitzwilliam Lodge had a clear and shared vision based on equality, inclusion, human rights and opportunity. Staff focused on people’s strengths, rather than the challenges they had faced, supporting people to build confidence, develop independence and work towards goals that mattered to them.

There was a strong sense of hope and possibility throughout the service. Staff saw people's potential and spoke with genuine pride about their achievements, progress and dreams. Conversations with staff reflected a shared commitment to helping people recover, gain independence, be part of their communities and build meaningful lives. Staff and leaders were extremely dedicated, consistently working towards the same goals and understanding what the service was trying to achieve for the people it supported.

This culture could be seen in the way people's lives, achievements and relationships were celebrated. A dignity wall recognised important milestones and successes, while a memory wall celebrated people who had been part of the service and the impact they had on others. A memorial tree provided a space for people to remember friends who had passed away and celebrate the lives they had lived. These were more than displays. They reflected a culture where people's stories mattered, where achievements were recognised, and relationships and community connections were extremely valued.

Staff looked beyond people's diagnoses and support needs. They knew what was important to them, what they enjoyed, what they wanted from life and what they hoped to achieve. As a result, people experienced a service that believed in their potential and fully invested in their future. People were supported to see opportunities rather than limitations, develop confidence in their abilities and build lives filled with purpose, connection and hope.

The provider had exceptionally inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of the organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively and consistently showed integrity, openness and honesty.

Staff retention reflected the positive culture leaders had created. Staff turnover was exceptionally low at 1.8%, and many staff had worked at the service for more than eight years. This provided people with continuity from staff who knew them exceptionally well and understood their individual needs, goals and recovery journeys. Staff consistently described leaders as supportive and spoke positively about the way they were supported through career progression, bereavement, poor mental health and changing family circumstances.

A carefully planned transition to a new registered manager further demonstrated this stability. The new manager was already known to people, staff and professionals, and handover arrangements were introduced well in advance. Relationships, values and ways of working were maintained throughout, giving people confidence that the culture and support they valued would continue.

Without exception, people, relatives, staff and professionals described leaders as visible, approachable and highly trusted. One person told us, "Wherever you are, [registered manager], it's always better," while another said, "We've been through hell and back and [registered manager] has always been there for me." Staff echoed these views, with one saying, "I could not have wished for a better manager." Professionals described leaders as “knowledgeable,” “responsive” and “respectful.”

Staff described receiving support through bereavement, poor mental health, childcare challenges and career development. One staff member described how leaders removed barriers to employment by adapting working arrangements to meet their individual circumstances. This enabled them to remain in work and later return to their preferred role. They told us, "I can't thank [registered manager] and [deputy manager] enough for everything." Another described how support and encouragement helped them overcome barriers, build confidence and progress into a leadership position.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People and staff felt able to speak up and were confident concerns would be listened to and acted upon.

Staff had access to speak up champions and whistleblowing arrangements. They were confident leaders would respond appropriately to concerns and understood alternative reporting routes if needed. Feedback from people and staff was welcomed, listened to and used to improve the service.

As a result, people and staff experienced an open culture where feedback was valued, concerns were addressed and improvements were made. Staff told us they were “encouraged to make suggestions and raise any concerns or issues that may affect the quality or safety of care”.

Leaders promoted equality of opportunity by recognising that staff did not all start from the same position and may require different support to succeed. They adapted support and working arrangements to reflect individual circumstances and remove barriers to employment. Staff described a workplace where opportunities were based on potential rather than personal circumstances. One staff member described how leaders adapted working arrangements to reflect changing personal circumstances, enabling them to remain in work and continue their career with the organisation.

Leaders worked creatively to remove barriers which may otherwise have limited opportunities for staff. This included providing additional support, flexibility and development opportunities tailored to individual needs. Staff described gaining confidence, developing new skills and accessing opportunities they may not otherwise have had. These approaches enabled experienced staff to remain in work, progress in their careers and continue contributing their skills and experience to the service. People benefited from continuity of care and support from staff who knew them well.

Staff gave examples of how leaders had recognised individual needs and taken action to promote equitable access to development opportunities. One staff member described how additional support helped them overcome barriers to progression, build confidence and develop the skills needed to progress into a leadership role. They told us, "During my time, I have had so much support that has helped me become a [leader]."

This inclusive approach resulted in positive outcomes for staff. Within the previous 18 months, 6 staff had progressed into more senior roles, including leadership positions. These outcomes demonstrated that opportunities for development and progression were accessible to staff from a range of backgrounds and circumstances. Staff also described support extending beyond their immediate job role, with one person telling us, "I am more than supported within my job role and my personal life." This demonstrated leaders' commitment to understanding and responding to the wider circumstances affecting staff, helping them remain in work and succeed”

Staff consistently described a culture where they felt valued, respected and supported. One staff member told us, "My manager is always supportive" and "[we] support one another, communicate well, and work together." Staff feedback showed leaders had created an environment where people felt able to succeed and develop as individuals.

The provider had highly effective responsibilities, roles, systems of accountability and governance arrangements. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Leaders maintained effective oversight through audits, reviews, meetings and action plans. They used this information to understand what was working well, where improvements were needed and how support could be made better. Information was reviewed regularly and used to make changes that improved people's experiences and outcomes.

People's views were actively used to develop the service. Feedback was reviewed, acted upon and shared through 'You Said, We Did' approaches. Changes included preferred meals being added to menus, increased opportunities for meaningful activities, improved access to advocacy information and greater involvement in care planning. A professional told us, "Concerns by the team are always fed back in a timely manner," while a staff member said, "I am encouraged to make suggestions and raise any concerns or issues that may affect the quality or safety of care." This demonstrated leaders had established systems which promoted openness, accountability and continuous improvement.

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 had developed strong relationships with healthcare professionals, social workers, mental health teams and drug and alcohol services. Professionals consistently described staff as approachable, responsive and professional.

People were supported to maintain links with their local communities through activities, community groups and social events based on their interests and preferences. This helped people remain connected to their communities and build meaningful relationships.

Partnership working helped ensure decisions reflected people's needs, risks and recovery goals. Staff worked closely with other services to coordinate support and respond to changing circumstances. One professional explained how a move which "could have destabilised [a person], was managed very well," helping them remain settled and continue progressing towards their recovery goals. Another said, "Their work often prevents residents with enduring mental health needs from requiring admission back onto the wards."

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.

Learning from reviews, audits, governance processes and feedback was used to improve practice. Care plans, staff guidance and training were updated when learning identified opportunities for improvement. Lessons learned were shared with staff and used to improve the quality and safety of support provided.