Crimson Manor

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

The service was in breach of legal regulation related to good governance.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a shared vision, strategy and culture based on transparency and engagement. We found when providing information of concern and requesting assurances; the registered manager’s responses did not always address concerns and offer assurances. For example, we found a number of concerns regarding the balance of medicines. When we raised this risk and requested assurances, we were told by the registered manager that this was due to expected staff/human error. We remained concerned about issues identified, but received no further reassurances that additional action would be taken (for example, re-training staff or checking their competency.

The service 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. During our inspection of the service we found multiple issues, these issues had not been identified by the management team prior to our inspection through management oversight of the service. Feedback from relatives was mixed and comments included “Registered manager is not very approachable and will just ignore you if she does not like you.” “I do not discuss anything with the management team there is no point nothing gets done anyway.” “They often chat with the management team when visiting relative.” “They found the management team very warm and welcoming and able to answer all of the questions they have.” All staff we spoke to spoke positively about the management team. They told us they provided support and felt the management team were both capable and compassionate.

Partners, health care professionals and some relatives told us about their experiences of not feeling listened to by the registered manager when raising concerns. However, staff feedback was positive and all staff we spoke to said they could speak up and raise concerns and would be confident managers would act on concerns.

All staff we spoke to told us the service always valued them as part of the workforce. They all said the service worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service 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. Quality assurance systems were not robust and did not identify the issues we found during the assessment. Care plans and medicines audits had not identified the shortfalls we found in those records. Which meant safe medicine practises were not promoted and care plans were not reflective of service user’s needs. We looked at care plans and found they contained inconsistent information. We found although care plans had a recent review date, not all information was accurate and reflective of the persons care needs.

The service did not collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with all partners or collaborate for improvement. During the assessment, we raised multiple concerns about the safety of the service. We experienced a lack of response to evidence presented and our requests for assurances. We received negative feedback from partners regarding their working relationships with Crimson Manor.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. All training was delivered by the provider’s management team. The provider did not engage with offers of training and support from partners. The registered manager told us they do not complete analysis of safeguarding incidents as these were investigated individually by local safeguarding teams. This did not allow any analysis of possible trends and themes to be identified to reduce the risk of reoccurring safeguarding incidents. This meant, there were missed opportunities for learning and development of the service.