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 changed to inadequate: This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care. The provider was in breach of legal requirements relating to good governance.

This service scored 29 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

Leaders did not demonstrate a cohesive or accountable culture. The provider had a long-standing pattern of non‑compliance, with improvements not sustained across multiple inspections. Despite repeated warnings from safeguarding investigations, complaints and regulatory feedback, leaders did not embed learning, and the same issues continued to reoccur.

The culture across units was inconsistent and did not reflect a shared set of values or expectations. People told us they often felt unheard, unsupported or unsure who to approach when worried. Inspectors observed long periods without engagement and staff responses that did not uphold dignity or person‑centred care. These findings demonstrated the absence of a shared culture that promoted inclusion, safety or respect.

Staff feedback was mixed. Some felt relationships were positive, but others described communication barriers, limited supervision, frequent staff changes and pressure from high agency use, all of which made it difficult to embed a consistent culture.

Overall, leaders did not demonstrate a shared, transparent or inclusive culture. This contributed to a fragmented service and inconsistent experiences for people.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Leadership oversight was insufficient to ensure safe and person-centred care. Despite repeated regulatory concerns, leaders had not taken effective action to address ongoing failures. Repeated breaches of regulation, ongoing safeguarding issues and continued poor practice reflected weak and ineffective leadership oversight.

Leaders did not act openly or transparently. A serious safeguarding incident that occurred during the assessment was not disclosed to inspectors, which was a significant breach of the Duty of Candour. Safeguarding notifications were also incorrect or missing, preventing appropriate external scrutiny. These issues raised concerns about honesty and accountability.

At the last inspection, the provider gave assurances they would review staffing across units and ensure leadership would be strengthened. This did not happen. At this inspection, there had been no changes to staffing structures, and recent changes were only made due to concerns found during this assessment. This demonstrated a pattern of reactive rather than proactive leadership.

Staff feedback reflected inconsistent leadership. While some staff felt supported, others described unclear expectations, inconsistent supervision, language barriers and a lack of leadership visibility. These issues contributed to varied practices and a lack of confidence among staff.

Overall, leaders did not demonstrate the capability, openness or credibility required to ensure safe or effective care.

People did not feel they could speak up and that their voice would be heard.

Although staff had formal opportunities to raise concerns through team meetings and group supervision, these mechanisms were not supported by a culture of openness and evidence showed that staff did not feel confident or safe to use them. Staff described inconsistent communication, limited supervision, and uncertainty about how to escalate concerns.

Policies for whistleblowing and raising concerns were in place, they were not effective in practice. Whistleblowing alerts were made directly to CQC rather than through internal channels. These findings indicate that, despite having mechanisms in place, the provider did not foster an open or transparent culture that encouraged staff to speak up.

Staff told us communication from leaders was inconsistent, supervision was limited, and they were often unsure how or when to escalate concerns. Several whistleblowing alerts were made directly to CQC regarding leadership and safeguarding, which indicated some staff did not feel confident raising issues internally.

Leaders recorded actions and learning from incidents within clinical governance meetings; however, staff described the same concerns recurring over time. This showed that governance processes did not translate into a culture where staff felt safe, supported or confident to speak up.

Overall, the provider did not foster an open or transparent culture where staff were encouraged, empowered or protected to speak up, as required under the Freedom to Speak Up Quality Statement.

The provider did not demonstrate that it valued diversity within the workforce or fostered an inclusive and equitable working environment. Although policies existed relating to equality, diversity, accessible information and reasonable adjustments, these were not effectively embedded into day-to-day practice.

Staff described language barriers within the team which affected communication, teamwork and their work experience. Leaders had not taken action to understand these barriers or to implement adjustments that would support a more inclusive working environment. Some staff also described unclear expectations and inconsistencies in how they were supported, which contributed to inequitable experiences across the workforce.

Leaders did not show an understanding of the workforce’s diverse needs or take meaningful steps to promote fairness or inclusion. This meant staff did not consistently experience a workplace culture that respected or responded to diversity.

Overall, while EDI policies were in place, they were not translated into practice, resulting in a workforce culture that was not consistently inclusive, equitable or supportive.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance systems were not functioning effectively. Despite having robust policies, audits and clinical governance meetings in place, they were not implemented appropriately or effectively and these processes did not lead to improvements in people’s safety or experience. Leaders completed audits of care plans, medicines and incidents, but these did not identify or resolve the widespread concerns found at the service, during this assessment. Issues such as poor record keeping, missed observations, inconsistent care, poor medication management, and safeguarding patterns continued. Lessons learned were recorded, but they were not embedded, and the same issues recurred across units.

At the previous inspection, the provider stated that leadership structures would be strengthened through the introduction of unit manager roles. This did not take place. At this inspection, the staffing structure remained unchanged, and leadership changes were only made retrospectively after concerns were raised. This showed a lack of forward planning and ineffective delivery of previously provided assurances to required improvements.

Risk management processes were not effective. Key information about deterioration in people’s conditions, behaviours that challenged, falls management and medication concerns was not consistently monitored or escalated. Referrals to professionals for example mental health teams following changes in needs were not always completed or followed up.

Feedback from professionals about the service highlighted repeated gaps in communication, clinical oversight and staff practice. Whilst there had been some recent improvements in multidisciplinary working, these were not embedded or consistent across the service and did not result in sustained improvements to people’s care or safety.

Overall, the provider did not demonstrate effective or sustainable governance arrangements. Leadership oversight was weak, risks were not managed well, and improvements were reactive rather than planned and not sustained. This meant people continued to experience avoidable harm, inconsistent care and poor outcomes.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people.

Although the service offered a range of community‑based activities, including weekly visits to “The Bunker” for bingo, visits to St Luke’s Church for afternoon tea, and regular entertainers and cultural groups within the home, these opportunities did not compensate for the wider failings in partnership working. The provider had arranged some visits from local singers, choirs and faith groups and had created a multi‑faith room for people who wished to practise their religion. These examples demonstrated some positive community links, but they were not consistently accessible or meaningful for all people using the service, particularly those who were bedbound or living on units where staffing shortages limited participation.

Leaders did not demonstrate strong or consistent partnership working with health and social care professionals, and they did not ensure people were consistently supported to maintain meaningful connections with their communities.

Professional’s feedback highlighted the registered manager had been responsive to recent changes and attends the weekly Multi-Disciplinary Team Meetings (MDT), however there was inconsistent care between units and peoples clinical care needs was not always being met.

Relatives described limited communication when health needs changed, and several reported delays in involving external professionals when people experienced deterioration, behavioural distress or changes in mobility.

Leaders did not demonstrate effective partnership working to ensure safe and coordinated care. Governance systems failed to identify risks that external professionals repeatedly raised, and there was limited evidence that learning from safeguarding investigations, clinical concerns or deterioration had been shared meaningfully with health partners or used to drive improvement. Relationships with community organisations were present, but they did not address the significant gaps in health and social care coordination.

Overall, while some social and community links were in place, the provider did not ensure effective or consistent partnership working with external agencies to support safe, coordinated care.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The provider had policies and governance processes intended to support learning and there was evidence that leaders completed reviews of incidents and held clinical governance meetings to discuss concerns. However, these processes were not effective in ensuring changes were implemented or embedded. The same themes continued to appear across safeguarding investigations, complaints, inspection findings and professional feedback. For example, issues relating to poor record keeping, missed observations, responding when people’s conditions deteriorate, ineffective monitoring, and inconsistent escalation were repeatedly identified over an extended period. Despite actions being recorded, the underlying issues were not resolved, demonstrating that learning was not translated into practice.

Although governance systems and audits of care records were taking place, they did not identify or remedy the significant concerns found during the assessment. This showed that audit tools lacked depth, and impact, oversight and scrutiny by the provider and resulted in no meaningful improvement.

There was no evidence of innovation or forward planning to improve the quality of care. Leaders did not demonstrate insight into the challenges faced by the service or take proactive action to improve culture, staffing, risk management or clinical practice.

Leadership structures remained unchanged until after concerns were raised, despite previous commitments to introduce unit managers. Improvements were introduced only retrospectively and in response to regulatory intervention, rather than through proactive leadership.

Overall, the provider did not demonstrate a learning culture or commitment to continuous improvement. Ineffective governance, lack of accountability and failure to embed lessons from past incidents meant people continued to experience avoidable harm, inconsistent care and poor outcomes.