Archived: St Audrey's

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 requires improvement. At this assessment the rating has remained 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 provider continued to be in breach of the legal regulation in relation to good governance. People’s care plans and risk assessments were updated but ongoing reviews did not involve people and their relatives and were not completed in a timely way. Audits were completed with actions identified, but these were not always addressed.

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 provider did not have a clear shared vision, strategy and culture. The future of the home remained unclear and whilst decisions were still to be made, investment into the service was limited. This meant improvements due were not realised and there was a lack of motivation to make the necessary improvements at the service.

The lack of stable leadership and no new admissions to the service for a long time had an impact on staff and relatives who were anxious about the long-term plans for the home. A relative said, “We’ve asked in relatives’ meetings about the number of residents and how long before it is not considered viable; must be running at a loss. They were not considering taking more on until the manager is settled in.”

A member of staff said, “I just feel that no one cares about St Audrey’s from Ambient. All the other homes have got manager, deputy, care team leaders, seniors etc and we are just left to fend for ourselves as no permanent manager and don’t even think they are advising for 1.”Another staff member told us, “I feel the new manager does not share anything with us, I found out the other day that the embargo [restriction on admissions] had had been lifted and the manager did not share this with us.”

However, we were also told of improvements since the new manager joined the service. Staff told us they had been able to order smaller items which improved the home for people. A professional said, “There has been positive movement within the service since [manager] has started and notice how staff seem more empowered.”

The provider had not ensured there was stable leadership at the service which had been without a registered manager since 2022. The current manager was the third in post since our last inspection in July 2024 and this continued to affect staff morale, although some staff were positive.

A staff member said, “It’s just the change of managers. A lot of comings and goings – here we go again. Managers do things differently, but I feel we are getting used to a new face again and I think staff feel a bit more confident and settled.” People’s relatives felt confident in the new manager. A relative told us, “[Manager] appears on the ball.” Another relative said, “[Manager] is new and relatively helpful, and I have confidence in [them].”

However, the new manager had been in post a short time. Feedback from staff suggested it was not clear if this was a permanent arrangement. A staff member said, “I wouldn't put a relative in St Audreys until a permanent manager was appointed and the structure of the staffing was stable.” However, the manager had started the process to register with CQC.

Staff did not always feel they could always speak up and that their voice would be heard. The provider had a whistle blowing policy. This included guidance for staff on who to raise concerns with, including who to escalate to if their issue was with their manager.

Staff told us they knew who to speak to if they had concerns. However, the frequent manager changes had affected some staff’s confidence in doing this. A staff member said, “We have had so many mangers that no, I don’t feel I know who I can talk to or go to as we don’t know if we are coming or going. Too much change all the time no structure or consistence.”

The provider had policies in place to support fair treatment of staff. Staff gave mixed feedback about support from managers but felt supported by colleagues. A staff member said, “I feel the manager is too busy to support us [they are] always in the office with the door shut, I don't feel [they are] approachable.” However, another member of staff told us, “I know who to speak to when necessary and feel supported by the manager.”

The provider’s processes for monitoring the quality of the service were not effective. Whilst audits were completed, we found some of the issues identified at our last inspection in July 2024 remained. This was despite us service warning notices on the provider for failing to meet regulations. For example, we reviewed a care plan audit completed in December 2024 which included issues with food and fluid charts. The concerns identified remained during our visit.

Other audits identified the need for people’s life histories to be completed and activity plans to be implemented; these all remained outstanding actions during our inspection. This meant that the audits carried out were not effective because they did not lead to improvements being made, embedded and sustained.

The provider did not ensure records about the care people received were maintained accurately and contemporaneously. People’s care records were not always updated when required. The manager told us the aim was for these to be reviewed monthly; at the time of our visit this was not the case because only the manager and 1 other staff member were able to complete reviews. Since our visit more staff were able to complete these.

The process for monitoring Deprivation of Liberty Safeguards (DoLS) authorisations applications was not effective to ensure people’s freedom was only restricted when legally allowed to do so. Where needed, best interests decisions and DoLS applications were made. However, we reviewed the DoLS tracker and found it included people who no longer lived at the service. None were approved for the people who lived there, and we saw no evidence this had been followed up with the local authority.Following our inspection, the DoLS tracker was reviewed and updated.

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.

Other professionals told us communication with the home had improved since the new manager joined the service. A professional said, “[Manager] has advocated on behalf of our client and has tried to support them to obtain the services they need through funding and placements.” Another professional told us, “The manager is utilising this service well for ongoing staff support and training.”

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. There was not a clear plan for the future of the service and this meant there was a lack of investment into the home for improvements to be made.

The manager engaged with other services well and accepted support where available to help make improvements. A professional said, “The leadership team and staff have worked hard to make and sustain improvements in the home.” Another professional told us, “I find [the manager] proactive with suggestions.”

The manager was implementing ‘grab files’ which would be convenient for staff to use when contacting the GP or emergency services.