Cross Heath Grove

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 regulations in relation governance at the service.

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 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.

During this assessment, we identified shortfalls in the safety of the service and the support people received. Although warm and caring interactions were observed and feedback about staff was positive, the provider had not ensured effective systems were implemented to provide effective management oversight. This meant that the culture and quality of care experienced by people was not always consistent.

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

There were significant shortfalls in the leadership and management of the service. Leaders were approachable and most staff said they felt well supported. The registered manager was receptive to our feedback, and the provider took action or told us the plans they had to take action in several areas after concerns were raised. However, leaders had not provided effective day-to-day oversight. The registered manager was responsible for 3 other registered services, and gaps in the local management structure had affected leadership at this service. Significant concerns involving medicines, risk management, care records, restrictions and statutory notifications had not been identified or resolved before our assessment.

The provider promoted a culture in which staff could speak up and raise concerns. Staff told us they felt comfortable approaching managers and knew how to report poor practice or safeguarding concerns. They described using supervision, staff meetings and the on-call arrangements to share concerns and ideas. Staff also demonstrated an understanding of the need to document and report safeguarding matters. Most staff said managers listened to them, and one staff member said the registered manager welcomed staff opinions and acted when something was not right.

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 valued workforce diversity and most staff described an inclusive and supportive working environment. Staff said managers were approachable, fair and interested in their wellbeing. They reported receiving supervision and being able to request support or provide feedback. Staff described working collaboratively.

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.

There were significant shortfalls in governance, management and accountability. Governance systems had not ensured the safe and effective running of the service.

Audits had not been effective in identifying and driving improvements; or were not in place. For example, medication administration charts audits were completed regularly after each person's stay. However, broader medicines audits, used to identify trends, errors and improvement opportunities across the service, were only completed annually. During this assessment, we found several issues with medicines management. We found discrepancies in how staff recorded the management of people's finances. There were no audits in place to monitor the management of people's money, which limited the provider's ability to identify errors, discrepancies or potential safeguarding concerns in a timely way. Care plan audits had not been fully effective in identifying and driving the required improvements in care plans. While checks from the provider has identified work was required in mental capacity assessments, these checks did not identify that sound and image devices were being used without the appropriate assessments and in people's best interests.

Policies were in place but were not consistently followed, including policies covering medicines and financial records. Leaders had not demonstrated effective oversight of patterns in safeguarding incidents and medication errors.

Statutory notifications had also been submitted against the wrong registered location or had not been submitted when required.

Following feedback, the provider described revised management arrangements. However, some of these processes were new and had not yet shown that risks were consistently identified, acted on and prevented from recurring.

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 provider worked with relatives, healthcare professionals and other services.

Relatives described positive communication before respite stays and said staff contacted them about changes in people’s health and support needs. Staff worked with healthcare professionals, including dietitians, community teams and pharmacy professionals. However, relevant information was not always recorded before people stayed at the service.

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. They did not always actively contribute to safe, effective practice and research.

Leaders had not always used information from incidents, audits and feedback to identify recurring issues and drive sustained improvement. We found concerns relating to medicines management, care planning and risk management that had been identified on more than one occasion. This indicated that learning was not always embedded or effective in preventing reoccurrence.