Cressington Court 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 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 changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider was in breach of legal regulation in relation to good governance.

This service scored 32 (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 shared vision, strategy and culture based on transparency, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.Although the provider told us they were committed to delivering high quality care, and staff understood the importance of doing so, this had not been effectively implemented or embedded within the culture of the service. Inconsistencies within the management team meant a lack of a shared direction, meaning the provider was not effective to drive improvements. Due to concerns we found relating to people’s finances, staffing and managing risks, failing to follow the principles of the Mental Capacity Act 2005 (MCA) and failing to ensure the environment met the specific needs of people with dementia we could not be assured staff worked effectively to support people.

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.The service was manged by the home manager, who was not registered with CQC, and they expressed to us they were keen to learn and develop to deliver person-centred care. As discussed in this report the home manager did not have key knowledge, relevant up to date skills or support needed to achieve person-centred care. We told the chief executive they had to empower the current home manager to give them the skills and knowledge to be able to make the necessary improvement required at Cressington Court Care Home.

The provider had a policy to support staff to speak up. This included information on when and how staff could raise concerns. We saw minutes of team meetings where staff were invited to give feedback about the service. People’s loved ones told us they could speak up if they needed to.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. There was no evidence staff were included in ways to drive the service forward and implement positive change. Staff told us about overseas workers having to do more hours and change job roles without consultation and when they could take their holidays.

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. Whilst the provider had some quality assurance systems in place, including various audits, these systems had failed because they had either not identified or addressed the concerns we identified. The governance systems failed to identify and make necessary improvements across the service to oversee the delivery of the regulated activity; accommodation for persons who require nursing or personal care.

The provider failed to carry out effective quality checks in relation to accuracy of the information in relation to people’s needs, risks, and the care delivered. Care plans had not been reviewed and updated to reflect changes in people’s needs. Records for assessing, monitoring, and reviewing risk had not been completed and lacked essential information about people’s needs. As a result, they did not demonstrate people received the care and support they needed to keep them safe. The provider failed to maintain oversight and scrutiny of people’s daily care records to ensure they were in receipt of safe, and appropriate care.

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 had been working with partner agencies to support improvements within the home. However, we found improvements were not sufficient meaning significant risks and shortfalls remained. Peoples loved ones confirmed referrals had been made to health and social care professionals to gain support about people’s needs.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not actively contribute to safe, effective practice and research. The provider did not have effective systems or plans to monitor and improve the quality and safety of the service. Audits did not always highlight recurring themes or trends, and there were no proactive plans in place to mitigate risks to people's wellbeing. Systems to review and learn from care records, documentation, personal finances and medicines management were not effective.