Carr Croft 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

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 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 governance.  

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 shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The provider did not always have a clear, shared vision and culture that was consistently understood and embedded across the service. The manger spoke about values around dignity, openness and improvement, and these were visible from them in the service. However, these values were not always translated into consistent practice. For example, while the manager promoted openness about incidents and safeguarding, we identified delays in learning and analysis of accidents and incidents, with some not reviewed in a timely way or lessons not fully embedded. Staff described the manager as approachable and visible, and most people and relatives experienced positive interactions and felt welcomed. 

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

While the manager was regularly present in the service, implementation and monitoring of systems and processes were not sufficiently effective to identify, address and mitigate risks and quality shortfalls within the service. This lack of effective oversight impacted the provider’s ability to ensure good governance, regulatory compliance, and consistent improvements in the quality and safety of care.

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

Staff told us they felt comfortable raising concerns and would feel safe to whistle blow if needed. Comments included “100% approachable, I always try and solve things, and I will tell the manager”, and “Yes, I am comfortable in speaking up to the manager definitely”.

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. People were supported by a diverse staff team, reflecting the diversity of the people living at the service.

Staff told us the manager and provider treated staff equally and they had not observed discrimination. The provider had an equality and diversity policy, and staff had completed equality, diversity and inclusion training.

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.

Governance systems were not fully implemented or effective in identifying and addressing risks. This included key areas such as care planning, fire safety risks, and other environment risks identified during our assessment. These findings demonstrated a lack of effective oversight and accountability. Governance systems were not always effective in ensuring records were accurate, complete and contemporaneous. People’s care plans contained contradictory information providing inaccurate guidance to staff. Systems operated by the provider were not robust to assess, monitor and improve the quality and safety of the service to ensure regulations were met.

There was a lack of formal provider oversight which had resulted in the failure to identify concerns around the service which has resulted in a breach of regulation in relation to good governance. Although regular provider visits took place, these were not always formally recorded, and there were no clear robust action plans produced by the provider to monitor progress or drive improvement.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The service worked with local GP surgeries and other healthcare services when required. However, the manager had failed to report some incidents to external agencies such as the local authority safeguarding team and CQC.

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, outcomes and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Although the provider had processes to seek feedback from people their relatives, staff and other professionals through satisfaction surveys, the process was not effectively applied to ensure learning and improvement took place. This was because the information gathered was not always analysed comprehensively to identify themes and patterns so action plans could be drawn up to address identified shortfalls. As a result, opportunities to monitor and enhance the quality of care were missed. During our assessment, we identified weaknesses in the implementation of the governance and quality assurance systems within the service and the lack of attention to detail, meant there was limited scope for the service to learn and to continuously improve.