FCNA Homecare

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 inadequate. At this assessment the rating has remained 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 regulation in relation to the governance of the service.
 

This service scored 36 (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. They did not always understand the challenges and the needs of people and their communities.

The provider’s culture was not consistently underpinned by shared expectations about accuracy, compliance or accountability. There was limited evidence that staff at all levels had a common understanding of their responsibilities for ensuring care was delivered safely, lawfully and in line with regulatory requirements.

Staff described a supportive day to day culture and one staff member told us, “Yes, [the manager] keeps us up to date and is always available. I love working here”. However, key governance gaps, such as missing recruitment checks, limited medicines governance and incomplete safeguarding and monitoring records, indicated that cultural expectations for quality and safety were not embedded consistently across the organisation.
 

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 provide assurance that they had the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

There was limited evidence showing how leaders consistently demonstrated inclusive leadership or how they assured themselves that staff were supported to raise concerns, challenge decisions, or contribute to learning and improvement across the organisation. The information provided did not clearly demonstrate how leaders actively sought staff feedback or created consistent opportunities for engagement beyond informal communication.

While staff described supportive interpersonal leadership, the evidence did not demonstrate how leadership behaviours were embedded consistently or how leaders assured themselves that inclusive and effective leadership was supporting safe, high‑quality care across the organisation.
 

Governance gaps limited assurance that staff concerns would be identified and acted on.

Leaders had not embedded reliable governance systems, as significant issues, including missing recruitment checks, inaccurate statutory information and gaps in safeguarding oversight, were not identified through internal audits. This limited assurance that staff could raise concerns or that these would be recognised and acted on.

Leaders confirmed that business continuity drills set out in the provider’s own plans to test staff roles, communication and response to disruption had not been undertaken in practice and that this had not been escalated internally. This reduced assurance that staff felt able or supported to raise concerns about preparedness or safety risks, or that learning and challenge were consistently encouraged.

The absence of medicines governance documents, MCA/Best Interests assessments and clinical monitoring records meant staff did not have structured processes to raise or report risk, limiting assurance that staff felt enabled or supported to speak up about safety.
 

We did not see assurance that diversity and inclusion were supported consistently across recruitment, training and supervision records. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Significant gaps were found across all staff files submitted, including references, and employment histories. These omissions were not identified by internal audits, which showed leaders did not have effective systems to ensure fair and safe recruitment.

Training matrices were inconsistent and did not align with certificates or the staff list, limiting assurance that all staff had equal access to essential training or development opportunities.

There was no evidence of structured supervisions or appraisals that could show staff were supported in a fair and consistent way, or that diverse needs and experiences were recognised and addressed.

Weak governance overall, meant leaders could not show how they created an inclusive environment where staff felt supported and treated equitably.
 

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.

Statutory information about the service was inaccurate. The provider was operating from an address that was not the registered location, and the Statement of Purpose contained incorrect details. These matters were only corrected following intervention by CQC, indicating weaknesses in governance controls to ensure regulatory information was accurate and up to date.

Governance arrangements did not provide assurance that people were protected through effective recruitment or ongoing risk management. Staff files contained significant gaps, including missing employment histories and references, and the registered manager confirmed these records had not been audited prior to the inspection. In addition, key information needed to support oversight of medicines, safeguarding and lawful decision making was not consistently available. Leaders could not demonstrate how these risks were routinely monitored, reviewed or acted on.

Arrangements for business continuity and serious disruption were not effective in practice. Although the provider’s own plans required testing of emergency response, leaders confirmed that no practice exercises had been undertaken and staff had not been briefed on their roles. Responsibility for reviewing and testing these arrangements was unclear, limiting assurance that the service could respond safely and sustain delivery during disruption.

Overall, there was limited evidence of routine audit activity, quality review or learning processes to support effective oversight, continuous improvement and long term sustainability.
 

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

There were some examples of effective partnership working within the evidence. For instance, the provider engaged with occupational therapy to resolve equipment issues, including arranging repairs to faulty bed control equipment, and the Admission Avoidance Team contributed short‑term clinical advice during acute episodes. These interactions showed that individual professionals were sometimes involved at the right time to support people’s needs.

The provider also participated in external quality monitoring activity. The Local Authority Quality Monitoring Team confirmed the manager engaged in weekly calls regarding care planning improvements. However, the provider did not demonstrate consistent or reliable systems for sharing information with partners. Key governance documents, such as MAR samples, PRN protocols, MCA assessments and outcome monitoring data, were not submitted in full during the assessment, meaning there was limited evidence that information was available to external professionals when required. Safeguarding relevant incidents, including falls and environmental hazards, were not logged as screening decisions or threshold outcomes, which restricted opportunities for multi‑agency learning or appropriate escalation.

The inaccuracy of statutory information, including the incorrect registered location and outdated Statement of Purpose, may have reduced confidence that information shared with partners was accurate and up to date. Without structured processes for information sharing, review or follow up, leaders could not demonstrate that partnership working was embedded or used to drive wider improvements across the service.
 

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 did not submit evidence of structured learning, post‑incident reviews or trend analysis, including for falls, refusals, environmental hazards or safeguarding‑relevant events. This meant they could not demonstrate how they identified themes or improved practice over time.

Medicines audits that were submitted routinely concluded, “no action needed”, despite clear gaps in documentation and oversight, which showed audit tools were not used to support improvement or drive learning.

There was no evidence of innovation, improvement planning or involvement in sector‑wide practice development, and leaders did not present systems for testing new approaches, evaluating performance or sharing learning with partners.