Crowley Care Homes Ltd - St Annes Care Home Also known as St Annes 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

We identified 1 breach of the legal regulations. The governance systems in place at the service were not effective in identifying areas for improvement and taking action to improve the service. Although systems were in place to support staff, we received mixed feedback from staff about the management and leadership of the service. There had been no improvement at the service since our last inspection and some areas of the service had deteriorated.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We received varied feedback from staff about the management and culture of the service. Most of the staff we spoke with told us there was good teamwork in the service and that all staff worked together for the benefit of people who lived there. However, some staff said it was difficult to raise any ideas for improvements as they were not listened to by management. Some staff were unable to tell us what the values of the service were. The provider sought feedback from staff on the quality of the service. However, no analysis of the staff feedback took place, and it was unclear whether any actions to drive improvement were implemented as a result of staff feedback. Staff feedback was not completed by enough staff to provide an accurate overview of staff opinions of the service. The low completion rate had not been followed up.

Staff attended handover meetings between shifts to promote information sharing and communication. However, records of these meetings were not detailed enough to support effective communication between staff. There was a risk that information about people’s needs would not be effectively communicated between shifts. The provider held management meetings with the registered manager and deputy manager, but minutes did not record any discussions about the culture and values of the service and how these could be developed. People were not receiving care that consistently met their cultural needs and this had not been identified. The provider’s statement of purpose did not provide people and their relatives with accurate information about the service. Information about the regulated activities the provider was registered with CQC to provide was incorrect.

We received mixed feedback about the quality of the leadership of the service. Some staff told us the management team were approachable and they felt listened to. However other staff said they were not confident in the leadership of the service as they did not feel all staff were treated fairly.

Processes were not effectively implemented to help make sure the management team were capable in their job roles. The provider could not be confident the processes they had in place for monitoring and improving the quality of the service were used effectively. We identified multiple areas of concern during this assessment. These had not been identified by the management and leadership within the service. There was no clear support structure in place for the management team in the service. In addition, the provider undertook no audits, they could not be assured capable, inclusive leadership was in place.

The provider could not be assured all staff were confident to ‘speak up’ or raise concerns when required. Not all staff were confident they would be listened to if they raised concerns with the management team. However, some staff told us they were encouraged to raise and concerns and were happy to do so.

Staff surveys were in place to provide staff with a forum to give their views. However, the low response rate to surveys meant the provider could not be assured they had captured a true reflection of staff thoughts and opinions of the service. Regular staff meetings were held but night staff told these were held during the day and they had difficulty attending. There was a risk night staff would not have an opportunity to have their voice heard. A whistleblowing policy was in place, this informed staff how they could raise concerns.

We received mixed feedback from staff about the management of equality, diversity and inclusion. Some staff did not feel they were treated fairly. They were not confident to share their ideas with the management team as they did not believe they would be listened to. However, other staff said they felt all staff were treated fairly.

The provider had processes in place to promote equality and diversity in the service and key documents such as the provider’s statement of purpose described how equality was promoted. However, the processes in place had not resulted in an equitable experience for all staff.

The registered manager acknowledged that improvements needed to be made to the oversight and governance of the service. However, insufficient action had been taken since our last inspection to improve the ongoing failings identified during this assessment.

The provider had failed to ensure governance processes were effective. The systems in place had not resulted in timely improvement to the areas of concern found during the assessment. There was poor governance and a lack of ongoing monitoring of care documentation. People's care plans, risk assessments and mental capacity assessments contained incomplete information about people's needs. There was a risk people would not receive appropriate care. The provider failed to have effective oversight of the nutritional and hydration needs of people living at the service. Records used to provide oversight of people’s dietary needs were inconsistent and did not correlate with the information contained in people’s care plans. The systems in place to assess, monitor and mitigate environmental, fire safety and infection control risks were not always effective. There was a lack of oversight of safeguarding and accidents and incidents. There was a lack of oversight of recruitment procedures and staff training. Recruitment records were incomplete. Mandatory training had not always been provided as required. The provider failed to implement a system to assess that staffing levels in the home were adequate. Staff spoken with during the assessment raised concerns about the staffing levels at night. No process was in place to ensure staffing levels were adequate to safely meet the needs of the service users living in the home. Failure to maintain oversight of quality monitoring processes placed people at risk of receiving poor care.

People’s relatives told us staff worked well with other agencies when needed.

The registered manager confirmed they had regular meetings with partner agencies to ensure people received continuity of care. For example, the local primary care network.

Commissioners and Healthwatch told us the provider had worked well with them as they undertook their role. Healthwatch is an independent organisation that advocates for health and social care and ensures that the voices of the public are heard by decision-makers.

Processes were in place to ensure people were supported to access multidisciplinary services they required promptly when needed.

The registered manager described how they had worked to make improvements in the service, identifying redecoration of people’s rooms as a priority. However, at the time of assessment, we found multiple areas of concern in the service that that had either not been identified or addressed.

Processes were not implemented effectively to enable lessons to be learned and improvements made. Audits were not effective in identifying where improvements needed to be made. There had been no improvement at the service since our last inspection (report published 29 September 2021) and some areas of the service had deteriorated; the service was still not meeting the fundamental standards we expect from care services. Although the provider took immediate action to make improvements in response to our feedback following this assessment, we cannot be assured these improvements will be sustained and embedded.