Firbank House

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

Audits at the service were not always effective. The audits had not identified concerns found during the assessment process. Maintenance audits demonstrated that action to make improvements took a significant period of time to implement. Action plans were not effective or suitably robust to drive improvement at the time of assessment. This was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014. Staff and people spoke positively about the registered manager. They felt able to approach the registered manager with concerns and felt they would take appropriate action.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager told us they were motivated to drive improvement at the service however there were no clear timeframes for improvement. Following the site visit, the service implemented a timetable for care plans to be updated with appropriate risk assessments and improved. Staff told us there was good morale at the service and staff worked together as a team.

Policies in place promoted equality and diversity at the home. Systems in place at the service did not work effectively to drive improvements at the home. There was not always evidence that people and their families had been involved in post incident reflection to make improvements in their care plans and the care they received.

Staff felt supported by the registered manager. We received positive feedback about the registered manager. Staff told us they could approach them with any concerns and they felt that something would be done in response to their concerns.

Systems did not drive prompt improvements at the service. The registered manager completed monthly checks that the maintenance checks had been completed. The checks did not identify that there was outstanding work required regarding the emergency lighting. It took several months for the emergency lighting to be fixed at the service. Medicine audits failed to identify the concerns regarding medicines we identified during this assessment.

Staff told us they felt able to raise concerns with the registered manager. Staff told us they were confident the registered manager would respond appropriately to any concerns raised. The registered manager had supported a person to raise concerns about a member of staff from an agency and aimed to increase their confidence in raising such concerns at the time incidents occurred.

Meetings and supervisions were held on a regular basis with staff. These meetings and supervisions also gave staff the opportunity to raise concerns in a group setting or on a one to one basis with the registered manager. Information was available to staff around freedom to speak up and how to raise concerns.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager had completed audits at the service but these did not consistently capture all the relevant information. The registered manager and provider expressed the challenge of maintaining an older building and had a service improvement plan in place. Following the assessment, the registered manager had also implemented a realistic timeline for effective care plan audits to be completed.

Audits were not effective at driving sustained improvement at the service. The service improvement plan stated that a person’s care plan was incomplete after residing at the service for 15 days. This had then been addressed. However, at this inspection we found people who had been at the service since April 2024 did not have completed care plans in place. Following the assessment the registered manager put a care plan audit timetable in place to assist with driving improvements in care planning. The service improvement plan does not contain information regarding the emergency lighting requiring fixes. The service improvement plan does not provide an accurate summary of actions required at the service. The registered manager does not have an accurate oversight of the service from the audits being completed.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff told us they completed regular training at the service which they found useful to carry out their role. It was not always clear that staff were fully informed following outcomes of incident investigations at the service. The registered manager reviewed data at the service on a monthly basis. It was not clear how effectively this information was used to drive improvement at the service.

The service improvement plan lacked detail on how improvement would be driven at the service. This plan was not being updated regualarly and did not include some of the issues we found during the assessment. Following the assessment the registered manager provided a timetable for care plan audits to be completed.