The Firs Residential Care 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 good. At this assessment the rating has remained good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 79 (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 nominated individual and manager worked closely together to ensure staff understood the service’s values and expectations. This supported a consistent and unified approach to care across the service. Leaders demonstrated passion and commitment to improving people’s experiences and outcomes. They had a clear understanding of areas that required ongoing review and development, such as the environment, and were taking steps to address these.

The nominated individual regularly visited the care home and spent time understanding the experiences of people and staff. They also gathered feedback from people and their relatives, using this to plan future improvements. They recognised how investment in the environment and staffing contributed to better outcomes and experiences for people.

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.

People and their relatives knew who the manager was and told us they felt able to approach them at any time. Staff also told us they felt the manager was supportive and approachable.

The manager and deputy manager were visible within the service and promoted open communication. Initiatives such as a weekly ‘coffee with the manager’ provided regular opportunities for people, their relatives, and staff to share feedback, ask questions and feel involved. There was an effective on call system in place, to ensure management support was available outside of normal working hours.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The manager promoted a culture where staff felt able to speak up and share their views. A range of feedback methods were in place, including face-to-face discussions, formal feedback processes, and anonymous opportunities, allowing staff to raise concerns or ideas in ways that suited them. Staff told us there was an ‘open door’ policy at the care home, and they could speak with the manager when needed.

A Freedom to Speak Up policy was in place, and designated staff members acted as Freedom to Speak Up champions. This provided staff with accessible support and encouraged openness across the service. Staff told us regular meetings and supervision sessions took place, giving them ongoing opportunities to share ideas, discuss concerns, and provide feedback.

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.Leaders promoted equality, diversity, and inclusion within the workforce. Staff told us managers supported them in a fair and non-discriminatory way, and their rights were respected. This helped staff feel valued and supported in their roles.

Managers demonstrated respect for staff’s protected characteristics, including age, race, disability, and religion or belief. Staff were treated with dignity and respect and were given equal opportunities within the service. One staff member told us, “Management make [staff] feel very valued. We are allowed to bring ideas to management for discussion.”

Staff told us they felt confident that any concerns relating to equality or discrimination would be taken seriously. Training in equality and diversity was provided and regularly discussed during supervision sessions and team meetings, helping to maintain an inclusive and respectful working environment.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Effective systems were in place to monitor the quality of care and people’s experiences. Leaders carried out a range of internal audits which included out of hours visits, checks on care plans, medicines, health and safety, and infection control. In addition to internal oversight, the provider used an external consultant to review the service’s quality and compliance which provided further assurance. We found actions from these checks were planned and completed.

The manager and nominated individual were open, transparent, and responsive throughout the assessment, supporting a positive and well-led service.

The provider understood their duty to collaborate and work in partnership, so services workedseamlessly for people. They shared information and learning with partners and collaborated forimprovement.

We received positive feedback from health and social care professionals who worked with the service. They spoke about the improvements made in recent years and the provider’s ongoing dedication to improving care, seeking feedback, and acting on it. For example, 1 healthcare professional told us, “Over recent years, I have noticed that the home has made significant strides in enhancing its management and overall care for [people].”

We saw evidence that feedback was acted upon and that the service actively looked for ways to strengthen partnerships and build community links. This demonstrated a strong, collaborative approach which gave good outcomes and experiences for people.

The provider had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider supported the manager and deputy manager to lead a practice-based quality improvement initiative, involving people, their relatives, and health and social care professionals, to improve wellbeing and reduce distress for people living with dementia.

A key aspect of this work was the shift from a reactive model of care to a more personalised, proactive approach grounded in emotional understanding. An emotional mapping model was implemented over time to identify patterns, triggers, and trends associated with distress. These insights informed care plan reviews and supported reflective team discussions, enabling staff to recognise that some incidents could be predictable and linked to specific events or circumstances.

As a result, staff were better equipped to deliver consistent, timely, and effective support. Improvements were seen in de-escalation techniques and continuity of care, with staff reporting increased confidence and competence in meeting people’s individual needs. This approach demonstrated a well-embedded culture of continuous learning and meaningful innovation, leading to improved experiences and outcomes for people.