Finch Manor 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 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.

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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. The provider had systems in place to discuss the shared vision of the service with people such as clinical reviews, team and people meetings, however, since our last assessment leadership had changed again. We also observed the quality of people’s experience differed in different parts of the service. Further time was needed to embed a positive and consistent culture. Staff did speak positively about working at the service. One staff member commented, “I enjoy it, and I feel settled."

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

Throughout this assessment the management team remained committed to improving the quality of the service and eager to demonstrate ongoing improvements. A new manager had been appointed since our last assessment and was in the process of registering with CQC. Staff spoke positively of this appointment, and we were told, “The manager is responsive and supportive."

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had policies and procedures in place which guided staff through the process to speak up. Staff told us they felt confident to speak with the new management team and felt they would be supported through this process.

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. Policies and procedures were in place to ensure people were treated fairly and equitably. This included when staff had protected characteristics under the Equality Act 2010.

The provider did not always have fully effective systems of good governance. The provider had continued to embed the governance systems which had been introduced prior to our last assessment. However, further work was needed. For example, medicines systems still had areas of improvement. The manager was aware of many of the other shortfalls we found, such as gaps in care monitoring records. We also saw records which demonstrated these issues had been raised with the staff team.

The manager was open and transparent when we raised issues. They told us they had recognised leadership in the home needed to be strengthened. Recruitment was underway to appoint unit managers to ensure improved oversight of both the quality of records and the experiences of people who lived at Finch Manor Nursing Home.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The manager was working closely with other professionals and taking proactive steps to improve collaborative working between services. Partners who worked with the service told us of recent improvements, but noted improvements were too recent to conclude these improvements were fully sustained into practice.

The provider had systems to focus on continuous learning, innovation and improvement across the organisation. Provider newsletters had been developed to share learning and best practice across different locations. Systems to demonstrate learning and improving from events which occurred had improved. Meetings with residents and relatives were planned and recently taken place. The manager was still embedding themselves and forming relationships with people, those people important to them and staff. Further focus was needed to demonstrate how this was having a positive impact on the quality of the service.