Crescent 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

Well–led - This means we looked for evidence that the leadership, management and governance of the service assured high-quality, person-centred care, supported learning and innovation, and promoted an open and fair culture.

At our last assessment this key question was rated Good. At this assessment, the rating has changed 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. The provider has failed to have sufficient governance and oversight arrangement in place to ensure systems and processes were effective to assess, monitor and improve the quality and safety of the service.

This service scored 57 (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 and consistently shared vision, strategy and culture based on transparency, equity, equality, human rights, diversity and inclusion. Although some values and good intentions were evident, the overall direction was not well embedded or consistently understood by staff.

At the time of inspection, there was no registered manager in post, and the service had been without stable leadership for several months. The recruitment of a manager was underway. Deputies and compliance staff were keeping the service running with the support of the provider, but governance oversight was reactive rather than proactive. Many of the shortfalls identified during the inspection, such as incomplete care plans, poor oversight of audits, inconsistent mealtime experience, and unclear staff induction, had not been identified by internal monitoring systems. This indicated that leadership and communication pathways were not yet effective in promoting a cohesive culture of accountability and shared learning.

Feedback from new staff indicated that the induction process was inconsistent and lacked structure, leaving some staff underprepared for their roles. This had not been identified by the provider and requires review and strengthening to ensure new employees are fully supported and competent before working independently.

There was evidence that the provider and senior staff responded positively when concerns were raised, and action was quickly taken in response to our feedback to address immediate risks, such as replacing faulty equipment and reviewing documentation.

Staff described the provider as approachable and supportive, and there was a willingness to learn from incidents, safeguarding investigations, and complaints. However, not all staff felt equally supported or listened to. Some reported low morale, unclear expectations, and poor induction experiences, which suggested that the provider’s cultural values were not consistently modelled or reinforced across the team

Not all leaders consistently demonstrated the skills, experience and oversight needed to lead the service effectively. Although the provider promoted an open and inclusive culture, the absence of a registered manager had affected the consistency of leadership and day-to-day management.

The provider and senior team were visible in the home and maintained regular contact with staff. Staff described the provider as approachable and willing to listen to feedback. However, some said communication and follow-up were not always clear. This meant staff did not always feel fully supported in their roles or confident that concerns would be followed up promptly.

We found the provider demonstrated openness, honesty and accountability. Duty of candour was evident through written responses to incidents that included apologies and explanations of lessons learned. The provider responded positively to feedback during the inspection and immediately began strengthening leadership arrangements, including reviewing management responsibilities, supervision processes and the escalation of concerns.

A new manager had been appointed and was due to commence in post, with support from the provider and senior team to ensure a smooth transition and improve consistency in leadership oversight.

The provider acknowledged the need to strengthen day-to-day oversight and ensure leadership capacity was sufficient to maintain consistency across all areas. Plans were in progress to stabilise the management structure, increase accountability and provide additional leadership support within the home.

Leaders demonstrated compassion and commitment to improvement, and the forthcoming appointment of a new manager will help provide greater stability and consistent oversight.

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

Staff, people and relatives told us they felt comfortable raising concerns or sharing feedback. One relative said, “If I ever have a concern, they sort it out quickly,” and another told us staff were, “Always open to listening.”

Staff said the provider and senior team were approachable and visible within the service. They felt able to raise issues directly, although some said they did not always receive feedback on what action had been taken afterwards. This meant the process for closing the communication loop could be improved to help staff feel more assured their views were acted upon.

Records showed concerns raised by staff or relatives were acknowledged, investigated and responded to appropriately. Duty of candour was evident in the provider’s written responses, which included explanations and apologies where things had gone wrong.

Regular meetings gave people and staff an opportunity to share ideas, raise issues and discuss improvements. The provider demonstrated openness during the inspection and took immediate action in response to feedback, showing a willingness to learn and improve.

The provider promoted an open and transparent culture where people felt able to speak up and contribute to improving the service, though communication about follow-up actions could be made clearer.

The provider valued diversity in their workforce and worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The staff team reflected a range of cultural and ethnic backgrounds. Staff said they worked well together and supported one another. Interactions observed during the inspection were respectful, and teamwork across shifts was positive.

All staff completed equality and diversity training as part of their mandatory programme and understood the importance of treating colleagues and people with respect. There were no reports of bullying or discrimination, and staff said they felt treated fairly and equally.

Staff said the environment was generally inclusive, although some commented that communication and recognition could be more consistent to help everyone feel equally valued.

The provider maintained a fair and respectful culture that celebrated diversity and supported equality within the workforce, while continuing to strengthen consistency in communication and recognition.

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

The provider did not use governance or quality-assurance systems effectively to identify risks or monitor the quality and safety of care. Although regular checks and audits were carried out, they were not sufficiently robust to detect the range of issues identified during this inspection. Key shortfalls in areas such as care records, environmental checks, infection control and medication oversight had not been recognised through the provider’s internal monitoring processes. This showed that the governance systems in place were not operating effectively or driving sustained improvement.

Some audits, including infection prevention and control and health and safety, were only completed annually. This meant that ongoing risks were not identified or reviewed in a timely manner. Similarly, medication and care plan audits were basic and focused mainly on administrative checks rather than assessing the quality of practice or the accuracy of information recorded.

Evidence of key safety checks, including weighing scale calibration and a comprehensive fire risk assessment, was not available at the time of the inspection. These were arranged after we highlighted the gaps during the inspection. While this was a positive response, it showed that the checks had not been planned or monitored in advance and pointed to a lack of effective managerial oversight.

Although we identified shortfalls during our assessment, there was evidence of a learning culture and a willingness to improve. Once issues were identified, the provider and senior staff acted promptly to address them and gave assurance that audit processes would be strengthened and carried out more frequently. Staff spoke positively about the provider’s responsiveness and commitment to making improvements.

The provider had governance frameworks and audit tools in place, but these were not used consistently or effectively to provide reliable assurance. Oversight was inconsistent, information was not always acted upon promptly, and quality-assurance activity did not lead to demonstrable or sustained improvement.

The provider understood their duty to collaborate and work in partnership, so services operated smoothly for people.

Records and feedback showed staff worked well with external health and social care professionals. People were referred promptly to GPs, district nurses, physiotherapists, dietitians and other specialists when their needs changed. Guidance from visiting professionals was recorded in care plans and followed in practice, ensuring advice was acted on consistently.

The provider maintained regular contact with commissioners and external agencies and was open and transparent in sharing information. Staff told us communication with health professionals was positive and that joint visits or calls were used to coordinate people’s care.

People were encouraged to stay connected with the community and their families. Relatives told us they were welcomed when visiting and described the home as “friendly and approachable.” Staff supported people to join group activities or spend time outdoors, helping maintain community links and social inclusion.

The provider responded constructively to feedback from external partners and acted on advice to improve practice. These collaborative relationships contributed to consistent, joined-up care and positive outcomes for people.

The provider worked effectively with professionals and the local community to ensure people received coordinated support that reflected their needs and preferences.

The provider did not always promote continuous learning, innovation or improvement across the organisation. They did not consistently encourage creative ways of delivering equality of experience, outcomes or quality of life for people, and were not yet fully contributing to the wider development of safe and effective practice.

The provider was committed to improving the quality of the service and responded promptly when concerns were identified. Immediate action was taken during and after the inspection to review record-keeping, and audit systems. However, governance and monitoring processes had not always identified issues in advance, and learning from incidents or feedback was not yet fully embedded in daily practice.

Governance relied too heavily on reactive measures, such as responding to incidents, complaints and safeguarding alerts, rather than proactive evaluation of quality and performance. Although a central log of incidents and safeguarding enquiries was maintained, we were not provided with adequate assurance that learning was consistently shared across the team or used to drive improvement. The provider acknowledged this and agreed to introduce a more structured action-tracking system to monitor progress and ensure improvements were completed and sustained.

There was evidence of action being taken when concerns were highlighted. For example, damaged equipment and missing PRN protocols were immediately addressed once identified. The provider also reviewed audit systems following feedback, showing a willingness to learn and improve.

There was evidence of early improvement work, including plans to strengthen performance management, support professional development and improve accountability. A new manager had been appointed to help embed these changes and promote a stronger culture of continuous learning and reflection.

The provider demonstrated openness and a clear willingness to improve, however, systems to support continuous learning and sustained improvement were not yet fully effective or consistently applied.