The Firefly Club 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

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.The service was in breach of the regulation in relation to good governance.

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 was in the process of improving the culture at the service.

At our last inspection, we found signs a closed culture had developed in the service. At this inspection we found improvements, and leaders were more alert to examples of poor culture to address these in a timely way. We found more transparency in incident reporting, people were being regularly supported to go out, the new registered manager was more present and leaders had more oversight. Staff comments included, “I’d say the general culture of restriction has improved hugely, there’s a lot more awareness of what restrictions are”, and “I think [registered manager] has been really focused on that [culture] change”. Although improvements had been made, we found some inappropriate language used in records and understanding of restrictive practices still needed time to embed.

Leaders embodied the culture and values of their workforce and organisation. Most staff we spoke with told us they were more confident with management since the new registered manager had been in post. A health professional also told us they had noticed great improvement in management of the service. However, the registered manager also managed another of the provider’s services, and the deputy manager spent most of their time providing direct support with only 6 hours dedicated to management tasks. Although they told us they felt supported, and the nominated individual was regularly present at the service, we could not be assured the provider had appropriate systems and support mechanisms to ensure the time and support needed to make improvements in a timely manner.

We received mixed feedback about whether staff felt able to speak up and their voice would be heard. Staff comments included, “I would say I’ve actually got a voice and it’s actually being listened to” and, “[Registered manager] has really done a lot here… she is approachable and I think concerns would be acted on”. However, other staff told us they did not always feel action was taken in a timely way when concerns were raised. For example, a staff member told us they felt the provider only made changes following external prompts, such as our inspection. We raised this with the provider, who told us they were working to improve communication with staff and ensure feedback was shared in response to concerns and ideas for improvement.

The provider was working towards embedding an inclusive and fair culture.

Staff survey results showed some staff raised concerns about gossip, morale and colleague relationships. The provider had an action plan in progress to improve this. We saw evidence of reasonable adjustments made to enable staff to fulfil their roles.

The provider did not always operate robust systems and processes to effectively assess, monitor and improve quality and safety. Although we found improvements since our last inspection, systems were not yet consistently effective or fully embedded. For example, audits had not identified shortfalls in medicines records and capacity assessments. When shortfalls were identified, they were not always acted on in a timely manner. For example, an October 2025 audit noted service user meetings would be introduced in November 2025. This was also identified in a January 2026 audit. At the time of our inspection, these had still not started. Notifications were now being submitted to CQC as required.

The provider understood their duty to collaborate and work in partnership, and shared information with partners. For example, a health professional told us information and concerns were now being shared and addressed, when they would not have previously.

The provider focused on continuous learning and improvement across the organisation. For example, they told us how learning was shared across the provider’s other services to promote improvement. The provider was engaged throughout the inspection process, demonstrated a clear desire to learn and improve and acknowledged improvements were a work in progress and needed time to embed.