St Audrey's

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• 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

The provider had not ensured the service had stable, effective leadership. Their governance processes were not robust in identifying and addressing concerns in the quality and safety of people’s care. The provider had not always engaged with people, relatives and other professionals effectively. However, staff felt supported and able to raise concerns.

This service scored 39 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff felt the lack of stable leadership at the service had an impact on their competency and morale. A staff member told us, “I have updated care plans myself as I wanted to help, but I was not trained to do this, and I frequently asked if I was doing it correctly and asked for training, which I have not received yet.” However, they also told us, “The staff do have a good support network with each other and try their best to help in stressful times such as not having a manager.”

The provider had policies to support equal opportunities and inclusion.

The service had been without stable effective leadership for a while. We received mixed feedback from staff about leadership of the service. A member of staff said, “When new manager comes it will be better. We all work as a team; we try our best for each other.” Another staff member told us, “The area manager has been very supportive given our current situation, however, that’s not always been the case. I feel the current area manager supporting the service has improved things and begun to address things for us.” We were also told, “No concerns as such whenever there is anything, the manager, we communicate with them, and they fix what they can do about it.”

The provider had not ensured the service had stable, competent leadership. The service had been without a registered manager since 2022. The most recent manager left a few months before our visit and had not yet been replaced. The service was being overseen by the area manager. Following our visit, the provider had recruited a new manager and had a plan to ensure they were supported. They told us, “We will have dedicated time for clear guidance and actions from our plan so we can see the progress being made for the time of their induction. I’m already allocating time for that to happen.”

Staff knew who to approach if they needed to raise concerns and felt comfortable about doing this. In addition to their manager, they mentioned other people within the organisation they could approach as well as the local council or CQC. A member of staff said, “If I had an issue with [manager] I would go higher and I would put it in writing.”

The provider had a whistle blowing policy. This included guidance for staff on who to raise concerns with, including who to escalate to if their issue was with their manager.

Staff gave mostly positive feedback about support from managers and colleagues, particularly in some difficult circumstances recently. However, we were also told of some issues with relationships among the team during this time.

The provider had policies in place to support fair treatment of staff.

The provider was aware there were a number of issues with the service. They had created an action plan based on feedback from the local authority. However, this had been given recently and at the time of our assessment there remained numerous issues.

The provider's governance processes had not been used effectively to ensure the safety and quality of the service. We found issues with their oversight of care planning, risk assessments, incidents, monitoring charts, staff competency and supervision and the quality of interactions between staff and people and engagement in meaningful activity. The provider had action plans to make improvements to the service. However, they had not identified and addressed these issues promptly and we were not assured how the improvements would be sustained.

People’s relatives felt communication with the home was affected by the lack of manager. A relative said, “It’s starting to bother me they have no manager or deputy. I feel that’s concerning…Lack of communication. The team are amazing, very strong team within the home, had a lot to deal with over the last year. It’s incredible how they have looked after each other in absence of not much management.”

The provider acknowledged there had been a lack of engagement with MDT meetings at the service in recent months.

The provider had started to engage more with other professionals. A professional told us, “I found [area manager] to be very engaging and keen to have some further training for the staff within the home.”

The provider had not always worked effectively to ensure prompt and accurate information was shared. They told us they had improved their processes since our visit to seek support from other health professionals and work in partnership to improve people's care.

Staff confirmed they were able to make suggestions to improve the service. A staff member said, “Yes – that was 1 of the main steps the admin and interim manager took when things were getting a bit tense because we lost 2 team leaders at the same time and the manager left. Everything, the pressure all came up. They organised meetings for how to make this work which was helpful.” The provider has been responsive to the concerns raised and requests for information. They have some action plans in progress for some of the concerns.

The provider had a team meeting with staff recently. We reviewed the minutes and found some information and updates given but there was no shared learning from incidents and no evidence of an opportunity for staff to contribute. The provider’s staff survey covered the whole organisation. This meant it was not clear how many, if any, staff from St Audrey’s responded and what their feedback was.