The Fairways

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.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 57 (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 shared their dementia strategy from 2024 to 2026 with us which outlined the provider aims and how this would apply to the service. However, we were not able to see how many of these aims applied in practice at the service. For example, it was recorded an aim was for dementia learning and knowledge to be added to team meeting from January 2025. We reviewed minutes from meetings held most recently and did not see this as an agenda item. Another aim was for dementia to be a standard agenda item on all future relatives’ meetings starting from February 2025. Minutes we reviewed did not discuss dementia and this was not a standard agenda item.

Concerns had been raised about poor moving and handling practice. The provider told us this had been addressed with staff in team meetings, and we saw this had been recorded in minutes. The acting home manager had told staff if they were observed using unsafe techniques they would be suspended. However, during our inspection we observed 2 occasions where staff used incorrect moving and handling techniques. This meant staff were not always understanding the provider values and aims to provide safe care.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. There was not a registered manager at the time of this inspection. The provider had informed us they were recruiting a new manager, and the deputy manager would step up to home manager in the interim. However, these arrangements had changed prior to our inspection, and the service was being managed by another home manager from one of the providers nearby homes.

People had not formally been told about management arrangements and there had been no introductory meeting with the acting home manager. Relatives had been told about the new arrangement the day before our inspection started. However, not all relatives had attended the meeting to hear this information. The provider told us following our site visit they had recruited a new manager. They said they would formally write to people and relatives to update them on the management at the service.

Staff said the acting home manager was approachable and they felt able to raise concerns with them.

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

Information about safeguarding and whistleblowing were available at the service. Staff told us they knew how to raise concerns and would know where to go if needed outside of the service.

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 had policies and procedures for equality, diversity and inclusion and provided staff with training. Staff said they felt welcomed at the service and enjoyed working there. They were aware of benefits available to them and could ask for reasonable adjustments if needed. One member of staff told us, “It is inclusive. Everyone’s opinion counts whether you are a care assistant or a senior. We have staff from different backgrounds and cultures, and we all get treated the same.”

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 effective in assessing quality and safety and did not support the provider to take action to mitigate risks.

Systems to audit care plans were not effective. Leaders completed audits on paper records and shared them with senior care staff to make the required changes. We found 1 care plan audit was missing so it was not evident if the actions had been completed. There were no timescales for completion, and it was not clear which senior staff would be responsible for making the required improvement. We found shortfalls in care plans such as incorrect names, dates of birth and genders. We found conflicting information and lack of details. Care plan audits had not identified these shortfalls.

Systems to check the safety and quality of the service were not effective. The acting home manager was completing daily walk arounds which were recorded. However, shortfalls such as screws sticking out of walls and cushions missing off seats had not been identified. In addition, gaps in daily cleaning schedules had also not been identified and action had not been taken to clean the service in specific areas. An odour from the communal toilets and bathroom had been investigated as not being a provider failure. However, there was no action plan or next steps to address how this situation would be resolved.

Provider systems to manage incidents were not being followed and this had not been identified by governance systems. This meant actions such as referrals to the local authority and notifying CQC had not happened. We reviewed incidents where a person living with dementia had been able to leave the home unobserved through a set of secure doors. Despite the repeated nature of these events, there was limited evidence that robust action had been taken to reduce the risk of recurrence. The primary measure implemented was a small notice displayed on the glass entrance doors asking visitors to ensure people did not leave behind them when exiting the building. This did not demonstrate a proactive or effective approach to managing known risks for a person at risk of leaving the service unsupervised. The lack of effective preventative measures and reliance on visitors to maintain the security of the environment placed the person at continued risk of harm. In addition, it did not provide assurance that lessons had been learned from previous incidents.

Following our site visits the provider told us they had taken actions to make improvements. They had installed a ‘turnaround’ manager at the service to support leaders and increased area manager visits.

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.

People were able to see GP’s weekly or more if needed. Where other healthcare services were needed, staff made referrals. Leaders recognised the need for collaboration with healthcare professionals. Following concerns raised by healthcare professionals about care, leaders met with them and agreed to work in partnership.

The provider did not always focus on continuous learning, innovation and improvement. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe and effective practice because systems for identifying trends, learning from concerns and embedding improvement were not consistently effective.

Leaders collected a range of performance data, including falls analysis, wound monitoring, call bell response times and behavioural monitoring records. However, this information was not always used effectively to drive improvement. Whilst trends had been identified, there was limited evidence of deeper analysis or evaluation of contributory factors. For example, falls data showed a higher number of incidents occurring during certain periods of the day, but staffing arrangements during these times had not been reviewed. Similarly, a significant increase in wounds had been recognised, yet there was no clear analysis of root causes or action plans to reduce future occurrences.

Quality assurance systems were not promoting learning or continuous improvement. Audits had failed to identify widespread issues within care records, including inaccurate information, gaps in risk assessments, incomplete reviews and inconsistent use of provider systems such as the ‘resident of the day’ process. Repeated concerns raised by people, relatives and staff regarding staffing levels, laundry services, hydration, environmental standards and the quality of the dining experience had not always resulted in sustainable improvements or timely action. This reduced confidence that feedback was being used as a learning opportunity.

There was also limited evidence that lessons learned from audits, incidents and complaints were put into practice. Although staff meetings included a lesson learned section and the provider shared learning from other services, we identified concerns relating to moving and handling practices, infection prevention and control, risk management and environmental safety. This indicated learning was not always embedded effectively or monitored to ensure improvements were sustained.

Following the assessment, the provider took action to begin addressing concerns, including increasing leadership oversight, introducing additional managerial support and commencing reviews of care records and governance processes. Whilst these actions demonstrated a willingness to improve, it was too early to assess whether they would result in sustained embedded improvements and better outcomes for people.