Crofton Springs

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

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 Good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff were supported by managers to deliver consistently safe, person-centred, and inclusive care and support to people in line with the provider’s vision and values for the service. A staff member told us, “The manager is very nice and supportive. The deputy manager is kind and helpful.” Systems and processes had been designed in line with this vision and focused on people and meeting their individual needs. The managers routinely used individual and group meetings to remind staff about the provider’s underlying core values and principles.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us they found senior staff and managers supportive and helpful. Their comments included, “The managers are approachable and they get involved with activities”, “Every day the manager comes on the floor and spends time with people. She asks if we need any help.” and “I think the manager is really good. She is fair but firm.” Where there had been past failings, the registered manager had completely re-focussed the priorities of the staff team to better support people’s needs and foster a culture of improvement. The manager was open about past concerns and where things had gone wrong and took responsibility for their actions. This meant the likelihood for reoccurrence was reduced.

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

People, relatives, staff and professionals told us they would feel comfortable in raising any concerns or making suggestions to the manager. One staff member told us, “Managers are very receptive when I give my opinions.”

The provider had requested regular feedback from people and their families and held quarterly meetings to seek people’s views and act on their feedback.

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.

Equality and diversity principles were embedded in practice and policy. The service was built on inclusivity and there was a diverse staff team who were encouraged to share their values and perspectives.

Staff had access to equality policies and training to help them understand diversity, protected characteristics, bullying and harassment. A staff member said, “It's a very good place to work. We are all treated fairly and equitably.”

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.

The provider did not have fully effective processes or systems in place for some elements of monitoring of the quality of care provided to drive improvements. This was especially in relation to record keeping for falls. The registered manager failed to operate robust quality assurance systems and processes to enable them to identify and act on information. For example, we found some falls had been recorded on one system, but not another, which meant falls audits would be incorrect.

The registered manager had not kept up to date with care plan reviews. This meant information was sometimes inaccurate and unclear. For example, we found in several care plans language was not person-centred. We found risk assessments were incorrectly showing people’s risk for areas such as falls and skin integrity. Information about people’s histories, likes and dislikes were not included. This meant opportunities to drive forward improvements to benefit people had been missed.

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.

Relatives told us they were invited to participate in care reviews and were kept informed of any changes made by professionals involved in their family member’s care. Professionals told us the staff team sought professional input as issues arose and have adapted well to meet the needs of people. Records demonstrated regular collaboration with a range of health and social care professionals.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Processes to review and identify any learning and service improvements following incidents were in place. Staff told us learning was discussed at staff meetings and there was evidence of this happening in meeting minutes and in handover documents. Specific training had been introduced after incidents and complaints which showed a learning culture and the provider strove to improve their services when things went wrong. However, incident and accident forms did not contain enough information on what mitigation was put in place after an incident and there was not enough detail around what lessons were learned. There was also a lack of continuity in some care plans to show which risk assessments had been amended following a particular accident.