Crown House 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. This is the first assessment for this newly registered service. This key question has been rated 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 at 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 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.

Many of the processes and procedures within the service required updating and modernising. For example, the provider had a number of audit templates in place, but they were outdated and needed improvement to enable the provider to capture all aspects of the service.

However, the registered manager fostered a positive culture where staff felt they could speak up and led by example in their interactions and kindness towards people living at the service.

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.

The concerns we found during this assessment had not been identified by the management team prior to our visit. Therefore, we were not assured all managers had full knowledge and experience of the requirements of the regulations.

However, leaders were visible within the service and there were opportunities for people to meet the manager.The management and staff team were approachable and appeared passionate about their roles. One staff member told us, “I think [registered manager] is a really good manager to be honest with you, [registered manager] is very good at listing if you have a concern about anything, if we do need [them] during the night for any concerns regarding residents or emergencies, [registered manager] is answering the phone. I find [them] very caring. I've got no problems whatsoever.”

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

People, relatives and staff told us they felt confident to raise concerns with the registered manager and these would be listened to and acted upon.One staff member told us, “I know that [leaders] appreciate us, [leaders] do listen to us, and if we have any concerns, [leaders] do say come to us, and don’t be afraid to come us. I feel we are appreciated as [leaders] are always there in case [we need support] and [leaders] show they are available to talk if we need them.”

Staff were aware of who they could contact, if they did raise a concern and felt they had not been listened to.

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.

The provider was able to describe what and how reasonable adjustments would be made for staff should it be required, such as amended working hours. We observed positive and kind interactions between the registered manager and staff.

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

The management team failed to complete effective audits and quality assurance processes to ensure care provided was safe, effective and responsive to people’s needs. Where audits were completed, we identified significant shortfalls in the quality of these audits as they failed to identify the widespread and serious concerns we found. For example, medicine audits were not effective, and there was no evidence the registered manager had oversight of these audits, when they had been completed by the deputy manager.

Systems and processes in place to gain people’s consent and make decisions were ineffective and did not demonstrate care was always provided in line with legal frameworks.

The provider’s systems and processes failed to ensure oversight was developed and maintained around environmental areas such as fire safety. Risks had been identified following a fire risk assessment in October 2023, however action was not taken until serious concerns were raised about this during our assessment. We shared our concerns with fire rescue services and partner agencies accordingly. Following this, the provider commenced a planned programme of works to reduce the fire related risks to people living at the service.

During our assessment we found the management team failed to notify CQC of significant events, such as serious injuries. These are required to allow CQC to complete their regulatory duties and ensure ongoing safe and effective care is provided. Therefore, the provider was not working in accordance with CQC regulations. The registered manager acknowledged these should have been submitted and did so retrospectively.
The provider failed to ensure all relevant policies and procedures were in place and they did not have effective systems to demonstrate staff had read and understood the policies or that these had been embedded in practice. Some policies had not been reviewed in line with the provider’s process to ensure they remained relevant and up to date, and some policies such as the medicines policy and evacuation policy failed to include critical information.

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 with them in delivering people’s care.

We saw evidence of external health professionals being involved in people’s care such as GPs, District Nurses and occupational therapists. We received positive feedback from both external health professionals we spoke to, with one stating, “I think their strength is their staff, in that there is good continuity and low staff turnover, as far as I witness, and also that the staff demonstrably genuinely care about the welfare of their residents. The residents are quick to praise the staff and have always seemed very settled and happy in the care home and happy with the care they receive. Often, if they become unwell, their main concern can be that they might have to leave Crown House, which I think speaks volumes.”

During the inspection, we identified a number of concerns across the service. These were communicated and shared with the provider, registered manager and directors. Leaders acknowledged that whilst the feedback was hard to hear, they accepted there were improvements to made within the service. The provider has demonstrated swift and robust responses to our concerns and has enlisted the support of an external consultant to help drive the improvements. The service has also received support from various stakeholders and has been working hard to begin making changes.

At the time of this assessment, the changes need further embedding to become part of daily practice.