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 the 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 inadequate. At this assessment the rating has changed to requires improvement. At the last assessment the service was in breach of legal regulation in relation to good governance. At this assessment we found the provider was in continued breach of good governance.

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. The provider had made significant improvements since the last assessment; however, more time was needed to ensure the organisation's vision, values and commitment to improvement were consistently embedded across all areas of the service. While progress was evident, some areas of practice required further development to achieve sustained and consistent outcomes. The registered manager understood the importance of promoting an open, inclusive and positive culture and took an active role in overseeing the service. This included regular walkarounds, observing practice and engaging with people and staff. The registered manager demonstrated the development of the staff and nurse forums, internal promotions and development opportunities for staff. These actions had contributed to improvements in staff morale, supported a more positive culture and helped drive improvements in the quality of care provided.

The provider had inclusive leaders at all levels in the service 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. Although significant improvements had been recognised and evidenced since the last assessment, further time was required to ensure new governance systems, processes and procedures were fully embedded, and consistency of improved practice was evidenced further. Staff described supervision as supportive and development-focused, providing opportunities to reflect on practice, discuss challenges and identify learning needs. Staff gave examples of how supervision had improved their practice, such as increasing their confidence in supporting people living with dementia and responding more effectively to people experiencing distress. Staff told us they had been supported to develop their skills and progress within the service. For example, one staff member had joined as a care staff member and, through training, mentoring and increased responsibilities, progressed to a senior role, a commitment to developing its workforce and could evidence staff progression within the service. The registered manager spoke about the support they received from within the wider organisation, which included access to senior leadership and peer networks. The leadership team, registered manager and staff were open, honest and responsive to feedback. They demonstrated a reflective approach and a commitment to continuous improvement, consistent with the ongoing improvement journey and promoted a positive and transparent culture.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People and relatives described open and trusting relationships with staff and management and told us they were confident any concerns would be listened to and acted upon. Staff told us they felt confident speaking with management if needed. Policies and procedures were in place to support speaking up. One staff member said, “Yes, I feel able to speak up about concerns I may have. If I have concerns or need guidance, [registered manager] is available to discuss them and provides constructive feedback. [Registered manager] encourages staff development and ensures we have the resources needed to provide good care.” The registered manager promoted a culture where people and staff felt their views were valued. They told us, “It’s about partnership working and making sure the residents and staff feel their concerns are valid and they have a voice.”

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. The provider promoted equality, diversity and inclusion within the workforce, creating a culture where staff felt respected, valued and supported. Staff were treated fairly and were encouraged to share their views, which contributed to an inclusive and positive working environment. This was supported by staff feedback. The provider recognised and responded to the diverse needs of staff. For example, reasonable adjustments were made to support staff with individual needs, such as adapted duties or working arrangements.

The provider had clear leadership arrangements and governance systems in place; however, these were not always fully effective in identifying and addressing risks. While significant improvements had been made since the last assessment, further time was needed to ensure governance processes were fully embedded and consistently effective in driving sustainable improvement. We identified ongoing concerns relating to medication management and the application of capacity and consent processes, which demonstrated established procedures and legal frameworks were not always being followed consistently. As a result, the provider remained in breach of the regulation relating to good governance.

The registered manager and provider completed a range of audits and quality assurance checks which generally identified areas for improvement and prompted timely action. However, while some of the medication issues identified had already been recognised by managers, others had not. The concerns we raised were addressed immediately to maintain people's safety.

The management team demonstrated an understanding of best practice guidance and promoted care that supported people's independence, choice and control. Clinical oversight had improved since the last assessment through the introduction of service-specific clinical reviews and strengthened oversight of clinical governance, procedures and pathways. There was clear provider oversight, with systems in place to monitor performance and share learning across the service.

People described the registered manager as approachable and helpful. Staff spoke positively about the management team, describing them as supportive and responsive, and told us there was an open culture where learning and feedback were welcomed. Relatives were positive about the changes in management and the improvements they had observed. One relative said, “Despite the facility's fluctuating CQC ratings, I have seen continuous improvements since [person’s name] admission. The management was honest about the challenges during the initial viewing and showed me the improvements they were making. I feel the passion and care is evident, and any query is sorted out right away.” Another relative told us, “I have observed significant improvements in staffing and management responsiveness, particularly since the new manager arrived. I feel confident, listened to, and believe [person’s name] is in the best possible place.” A further relative said, “Finch Manor is excellent and well-managed, I have no current concerns.”

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. We saw positive examples of partnership working with healthcare professionals to support people’s health and wellbeing needs. Management and staff demonstrated a good understanding of external services available and when to access their support. Feedback from partner organisations was positive and described collaborative working relationships, regular engagement and a shared focus on continuous improvement. Professionals recognised the progress the provider had made, identified areas of good practice and provided feedback on further development opportunities. One professional shared their regular contact and experience working collaboratively with the provider and described the staff as compassionate, resident focused and clinically aware.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. However, while improvements had been made since the previous assessment, learning and improvement systems were not yet sufficiently embedded to ensure consistently safe and effective practice. Concerns regarding medication management identified at the previous assessment were identified at this assessment. Ongoing concerns regarding medication management, evidence-based pain assessment and management, and adherence to capacity and consent requirements demonstrated improvements introduced had not always been consistently effective. The registered manager described how incidents, concerns and feedback were regularly reviewed to identify learning and drive improvements. Learning was shared with staff to improve practice. Staff were supported to complete additional training to develop within the service. The provider had plans to strengthen clinical leadership and oversight through the introduction of additional regional and clinical support roles. The registered manager demonstrated a commitment to ongoing improvement. They had reflected on feedback and concerns identified during the assessment and were taking action to drive further improvements at the service.