Crown Mews

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.
 

This service scored 61 (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 was in the process of embedding a shared vision, strategy, and culture across the service. The management team acknowledged that there had previously been “cultural issues” within the service. They recognised that person-centred care, alongside the promotion of independence and choice, had not been consistently evidenced by the staff team. This was due to shortcomings in both established practice and documentation. As such, the management team explained how they had developed a team plan outlining the “fundamental principles for Crown Mews.” They were committed to aligning the service with CQC’s ‘Right support, right care, right culture’ guidance. Relatives recognised this commitment and their feedback reflected a service that was improving but where improvements were still being embedded. One relative told us, “It’s a fresh start now. So, for the last 3 weeks they’ve responded well and I’ve witnessed a structured plan.”

The provider 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. However, this provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. At the time of our assessment there was no registered manager in post. However, a peripatetic manager had been appointed to oversee the service and was awaiting registration with the Care Quality Commission.

We found the wider management team to be open and honest about the challenges the service had faced, and they had clear plans to drive improvement going forward. Staff told us they felt supported by leaders and appreciated the clear direction and positive example they set. Another relative told us, “[New manager] has been great with communication and very quick [to take action].”
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. One staff member told us, “If I had any concerns, I would raise them and I know management would action them. I know I can go to my manager; I don’t need to wait for supervision. It is an open door. They are flexible.” Staff told us they felt supported by the manager and could raise suggestions or concerns. Staff understood the values of the service, and that their role was to also make the people who used the service feel cared for, respected and valued.

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. There was a diverse workforce at the service. We saw staff were included in discussions surrounding the support provided at the service. The provider supported staff equality and staff told us they were encouraged to be involved in the service and discussions such as updating people’s care records. The provider’s recruitment was equitable and fair.

The provider had governance systems to monitor and improve quality; however, these were not consistently effective. They did not always act on the best information about risk, performance, and outcomes, or share this securely with others when appropriate. While there was evidence of recent improvements in this area, further work was required to fully embed a robust governance framework. Although a Service Improvement Plan was in place, this had largely been driven by feedback from local authority contract monitoring rather than the provider’s internal governance processes. Medication, health and safety and financial audits were completed. Cultural and observational audits, walkarounds, and observational supervisions had also been recently introduced. Although these measures were beginning to drive positive change at the service, it was too early to determine their overall effectiveness.

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. Managers had good working relationships with partners including community health and social care professionals. One professional told us, “The provider is willing to liaise with professionals to support their residents effectively.” We saw evidence of effective partnership working, information sharing and collaboration to ensure people had a good quality of life.

The provider did not have a well-established focus on continuous learning, innovation and improvement across the organisation and local system. A service improvement plan was in place, which the provider was progressing to address identified concerns, with clear timescales set. However, these actions required further embedding and sustained implementation to ensure lasting improvement.