Fleetwood Hall

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 71 (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.

People and relatives praised the registered manager’s leadership and the culture of person-centred care. One person said, “They treat me with respect and affection.”

A second person told us, “If you have to live somewhere this is the best.”

Staff told us the management team spent time gaining their views and was committed to delivering the best service possible. One staff member told us, “It’s lovely to see [registered manager] interacting directly with residents. Some people are naturally kind and [registered manager] is one of them.”

The registered manager and deputy manager were supported by a regional manager and quality team who visited the service regularly and carried out quality assurance audits to monitor and improve the quality of care. Staff had access to an on-call system for advice and support outside of normal working hours, and senior managers were also available to provide additional support to the management team when required.

The quality director told us the provider was committed to developing leaders through ongoing training and support, explaining they worked with managers rather than assuming they already had all the skills and knowledge needed. Members of the management team spoke positively about the support they received. One manager told us, "Higher management are so involved." This demonstrated leaders were well supported and had access to effective oversight, guidance and development opportunities to help drive continuous improvement.

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.

Staff spoke positively about the leadership of the registered manager and deputy manager and described them as supportive, approachable and knowledgeable. Staff told us they felt valued and well supported in their roles. One staff member said, “I'm really happy, I could not have a more supportive person as my manager. I have learnt so much from observing [registered manager].” Another staff member told us, “[Registered manager and deputy] help out, you can't fault them. They are very approachable, you can talk about anything with them, so you are not carrying it.”

Relatives also spoke highly of the management team and the positive impact they had on people's experiences of care. One relative shared, “The managers have been amazing, not only with my [family member] but also with my [relative] when they visit. They genuinely care, always taking the time to listen, chat, and make them smile. They also keep us fully informed about my [family member's] appointments and care plan, which we greatly appreciate.” This showed managers were visible, promoted an open and supportive culture, and maintained positive relationships with people, relatives and staff.

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

The provider had a whistleblowing policy which staff had access to. Staff told us they knew how to make complaints and raise concerns. They could report concerns in 1 to 1 meetings and felt the registered manager had an open-door policy. They felt comfortable sharing any concerns with the registered manager who listened and acted on feedback.

The provider had formal processes to investigate concerns effectively and confidentially.

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.

There were appropriate policies to support workforce equality and diversity. Staff told us they felt valued and were confident the registered manager and provider promoted inclusion and equity. They said they had opportunities to share ideas for improving outcomes for people within group and one to one meetings.

Governance systems were not always effective in identifying, assessing and recording risks.

Provider audits had identified areas where recording practices required improvement, and action had been taken by the registered manager to strengthen oversight and documentation processes.

We found a small number of care tasks had not been reviewed and some care plans did not contain sufficiently detailed guidance on how staff should support people when they became distressed. However, staff demonstrated a good understanding of people's individual needs and were able to clearly describe how they would provide safe and effective support during periods of distress.

Following identification of these issues, the deputy manager and quality team took prompt action to review and update care plans and processes to ensure records more accurately reflected people's needs and the support required.

Managers completed daily walkarounds of the building to check the standards of care. This included, gaining feedback from people and visitors, the safety and cleanliness of the environment, people’s dining experience and staff wellbeing.

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.

Management and staff worked closely with relatives, health and social care agencies, the local authorities and CQC to drive improvement and meet people’s needs. One professional told us by email, ‘Management are very responsive to requests including providing information regarding the person, e.g. falls, incidents, weigh changes. Always answer the phone and people are available to talk to.’

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They 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 had installed smart lamps in some bedrooms to monitor people’s safety and wellbeing. The lamps could alert staff if people got out of bed or fell and the motion sensor lighting could prevent disorientation, trips and falls.