Cann House Care Home

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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

We have rated this key question requires improvement and have identified a breach of regulation in respect of good governance. The provider and management team had failed to operate effective governance systems and processes which did not identify the concerns we found at this assessment. This has led to failings in relation to the safety of the environment, safe care and treatment including medicines management, ensuring people’s rights were protected and governance systems and processes at the service.

Staff spoke positively about communication at the service and told us they worked in partnership with health professionals.

This service scored 57 (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’s statement of purpose stated that their philosophy of care is summed up by the statement ‘the hands that care.’ During our assessment we found staff treated people with dignity and respect and epitomised the providers vision and culture. One staff member said, “We build nice relationships with the residents and me personally I treat them like I would my own grandparents.” The registered manager told us staff worked well as a team to ensure people received the best care possible.

Staff spoke positively about communication and how the management team worked well with them, encouraged team working and an open person-centred culture. One staff member told us, “I want you to know that as a team we work really well and communicate really well, and I feel part of a family here and that I fit in, and I made to feel I am part of the team.”

There was a strong and established management team at the service to support staff with the delivery of care. However, although there was a strong management team in place, the management team and governance systems and processes in place, had failed to identify the issues we found during our assessment. This lack of oversight of people’s care placed them at risk of unsuitable or unsafe care.

Staff were aware of their roles and responsibilities and knew who to go to for help and support.

Systems and processes were in place to support people, relatives and staff to raise concerns and make suggestions. People and staff had confidence the registered manager and management team would listen to their concerns and would be received openly and dealt with appropriately. One staff member said, “I do feel the management are approachable and any of them listen to what your concerns are, and I have always had the support I needed.”

The registered manager worked in an open and transparent way when incidents occurred at the service in line with their responsibilities under the duty of candour. Any learning from accidents and incidents was shared with and discussed with staff.

The service valued diversity in their workforce and worked towards an inclusive and fair culture by improving equality and equity for staff who work for them. Staff told us they felt they were treated fairly, and the service was inclusive. The registered manager told us they celebrated staffs’ cultural diversity and supported staff with their religious needs where necessary. Staff were encouraged to share their culture with people and their colleagues. For example, with their permission, the staff picture identification board displayed staffs home country flags next to their photographs.

The provider did not have effective systems in place to monitor the quality of care and support that people received. Governance systems and oversight had not identified the concerns we found at this assessment. For example, in relation to the safety of the environment, monthly window audits had failed to identify windows were not all compliant with health and safety regulations. Environment audits and provider and management oversight had failed to identify the risks to people associated with unguarded radiators. Oversight of care delivery had failed to identify risks associated with people’s skin were not being fully managed and mitigated. Care plan audits had failed to identify care records did not always contain enough information to guide staff or were up to date and reflective of people’s current care needs. Medicines management and oversight had not identified staff lacked guidance and information about managing people’s diabetes in a safe way. The provider and registered manager had not ensured people’s rights were always being protected because the service was not always acting in accordance with the Mental Capacity Act 2005. Ineffective systems, processes and oversight has contributed to a breach of regulations in respect of good governance.

The provider had systems and processes in place to monitor care delivery and learn from incidents, accidents and complaints. However, systems and processes to ensure the service provided safe care, such as audits and management oversight, were not always effective as they had not identified the concerns we identified during our assessment.

The provider and registered manager were receptive to our feedback and told us they wanted to provide good care to people and their families. During the assessment and following our feedback, the provider took action to address the concerns.

The provider had systems and processes in place to monitor care delivery and learn from incidents, accidents and complaints. However, systems and processes to ensure the service provided safe care, such as audits and management oversight, were not always effective as they had not identified the concerns we identified during our assessment.

The provider and registered manager were receptive to our feedback and told us they wanted to provide good care to people and their families. During the assessment and following our feedback, the provider took action to address the concerns.