Fig House

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 continued breach of 1 legal regulation in relation to good governance.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider’s governance and quality assurance systems were not identifying all shortfalls so improvements could be made to the service.

The provider at our last inspection was in breach of 2 legal regulations. This was because the provider was not ensuring notifications were being made as required and the quality assurance systems did not identify areas of improvement.

At this inspection we found some shortfalls in notifications being made. The registered manager during our inspection took action to make these notifications. This meant the provider was no longer in breach of notifications. Although action was taken to make these notifications the provider’s governance arrangements had not identified this shortfall along with other areas of improvement needed during this assessment. The provider was therefore still in breach of 1 legal regulation of good governance.

For example, during our inspection we identified improvements needed to 3 people’s diabetes care planning information, risk assessments and mental capacity and best interest decisions for their diabetes care. We found 2 notifications had not been sent to the Care Quality Commission (CQC) as required for Deprivation of Liberty Safeguards (DoLS). Or where 1 notification was needed for a person who had sustained a serious injury. Another notification had been sent to CQC as a safeguarding. Although the person had sustained a serious injury and a notification should have been sent for this. The providers quality monitoring tool for safeguarding, incident and accidents, Deprivation of Liberty Safeguards had not identified these notifications had not been made. Improvements were also needed to the provider’s quality monitoring tool for safeguarding as this was not always confirming what learning and outcome there was from the concern raised.

The provider’s governance arrangements had also failed to identify improvements needed to ensure agency staff completed training to support people with their individual needs. This included where agency staff needed diabetes training. The registered manager took action during our inspection to; improve 3 people’s diabetes care planning information, risk assessments, mental capacity and best interest decisions relating to their diabetes care. Notifications were made, and they confirmed only staff who had been trained in diabetes care were to support the person with their care. Although, the registered manager took action during our inspection. Improvements were still required to the providers governance arrangements.

The provider had a service improvement plan in place. This identified actions needed, if they had been completed or if they were still outstanding. We found the action plan confirmed improvements had been made to people’s diabetes care plans and mental capacity assessments. Although during this inspection we found improvements were still required. We shared our inspection findings with the registered manager and the quality and compliance manager so they could review these shortfalls and any changes they needed to make to the service improvement plan.

The registered manager was supported by a deputy manager and a compliance manager and staff felt supported by the management of the service. Relatives felt able to raise any concerns with the management of the service and all confirmed they were very satisfied with the care and support provided at the service. The provider was displaying their CQC assessment rating within the service and on their website.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.