The Crown

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 requires improvement. At this assessment the rating has remained 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 43 (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 demonstrate a clear or shared vision, strategy or culture that promoted transparency, equity, human rights, or inclusion. Leaders did not ensure staff understood the values or purpose of the service, and there was no evidence of a meaningful culture that prioritised people’s safety, wellbeing or individual needs. Significant concerns identified during our assessment, for example, unsafe restrictive practices, inaccuracies in care records, and environmental risks, had not been recognised or challenged by leaders. Staff did not have the guidance or expectations needed to work safely and consistently. We found examples of staff injuries that had not been treated as incidents or used as opportunities for learning. This reflected a culture that did not prioritise staff wellbeing or support them to deliver safe and equitable care.

Leaders did not always understand the context in which care was delivered and failed to identify significant concerns, including unsafe restrictive practices and unreported incidents. They did not consistently demonstrate the skills, knowledge or oversight needed to ensure accurate records, effective risk management or compliance with legal frameworks.

Staff told us they felt able to raise concerns and believed they would be listened to. However, we found staff had experienced physical injuries and viewed these incidents as ‘part of the job’. This indicated that although staff felt able to speak up, we could not be assured their concerns would be escalated or addressed appropriately.

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 did not have effective governance arrangements in place. Roles, responsibilities and systems of accountability were unclear, and leaders did not act on reliable information about risk, performance or outcomes, nor consistently share this with relevant partners when required.During our assessment of The Crown, we identified multiple concerns, including three breaches of the legal regulations. Although some audits had been completed shortly before our inspection and reported no concerns, our findings did not support this. We identified significant shortfalls that the provider’s own quality assurance systems had failed to detect.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They had not always identified issues found during this assessment and therefore did not always share information and learning with partners or collaborate for improvement. For example, we identified a number of incidents that had not been identified by the provider and subsequently shared with the local authority safeguarding team and CQC.

The service did not demonstrate they had learnt and improved from our previous inspection. We identified similar shortfalls during this assessment. This meant we could not be assured leaders had a good understanding of how to make and sustain improvements at this service. This placed people at continued risk of not receiving care that met their needs and preferences.