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 inadequate. At this assessment the rating has improved to 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 good governance relating to provider oversight of the service and quality of care.

This service scored 61 (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 received care from a staff team who had a commitment to supporting people respectfully. Care records were person-centred and respectful. The provider followed their own supervision and support policies to reinforce their values and goals with staff. Staff were positive about the impact of the new registered manager. One staff member said, ‘[registered manager] models good care by doing shifts. Staff morale is good.’

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.

The registered manager had been in post for 3 months and was still in the process of embedding their strategies and plans for the service. Staff were positive about the registered manager. One staff member said, ‘The manager is really good, I feel supported and feel like I can raise any issues when I need to.’

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

People living in the home were encouraged and supported to express their views. Relatives we spoke with felt confident to raise any concerns with staff and leaders.

Staff we spoke with were aware of the providers policies in relation to speaking up and knew how to raise any concerns. Staff said leaders listened to them and responded to anything they raised. Information about how to raise concerns within the home and with other agencies were displayed in the home.

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.

Staff told us they felt valued and respected at work. The providers recruitment procedures considered people’s equality, diversity and inclusion.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

People did not receive consistently safe care because the provider had not ensured they had effective oversight of some risks and had not responded, in a timely way, to changes in people’s condition or needs.

The providers governance and oversight systems had improved, since we last inspected, however, there continued to be gaps in oversight which could have led to people experiencing harm. The checks and audits in place had not identified the issues we found.

The provider did understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners or collaborate for improvement. The provider continued to work in partnership with local commissioners and the quality improvement teams to develop the service. The provider had action plans and strategies in place to address the concerns raised at the previous two inspections. To be fully effective and support ongoing improvements the provider would benefit from these being streamlined.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. 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, effective practice and research. The provider was committed to learning and improvement, however their action plans still needed to be embedded to achieve this.