St Petroc's 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

The service was not well led and the registered manager resigned shortly after our assessment visit. The provider’s quality assurance systems were ineffective and senior managers had not visited the service regularly to monitor performance. A Notification submitted to the commission had contained inaccurate information. A culture of poor care had been allowed to develop and staff of different nationalities had been treated differently. Complaints and concerns received had not been robustly investigated by the provider. Staff who had reported safety concerns were fearful of retaliation from staff who had engaged in practices that did not promote good care.

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.

Some staff raised significant concerns about the culture of the service. Their comments included, “The staff will sometimes ignore people while having a chat rather than looking after people”. Staff reported they had witnessed occasions where staff had discriminated against a visually impaired person and failed to respond to their needs by becoming quiet and moving away when they requested support. Staff comments included, “There is not a team atmosphere here” and “I really really need to do something about what is happening here, I think it is my duty”. Staff who had reported safety concerns internally told us their concerns had been discounted by some colleagues and management. We found there was a closed culture within the staff team and people’s rights were not respected. One staff member told us, “I can see how some of the newer ones, when they saw [people being restrained and provided personal care] for the first time were confused”.

People living in the service were not valued as individuals and their decisions were not consistently respected. An indicator of poor culture within the service was the use of cut up towels, with frayed edges, as flannels during personal care. The registered manager was aware of this practice and told us, “I don't like them either.” However, no action had been taken to improve the quality of flannels prior to the assessment. Following feedback, the provider took immediate action and new flannels were provided. People’s care plans were inaccurate and did not provide staff with sufficient guidance to enable them to safely meet people’s needs. In addition, daily care records had not been consistently completed and did not demonstrate people’s needs had been met. The current staff team had limited knowledge of the provider’s care planning system and senior carers had been asked to take on responsibility for care planning without additional training. They told us, “Seniors do the care plan. Previously [the deputy manager] did them but now we are doing them.” People had not received care that was appropriate and met their needs. This was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff reported that the service’s leadership was ineffective, had failed to act on reported safety concerns and had allowed a culture of poor care and neglect to develop. One staff member described this by stating, “It is like a snowball, and I have seen it grow, the lack of care. They don’t care, so I don’t care”. Other staff told us, “The residents are absolutely lovely, management could be way better” and “There is not a team atmosphere here. There are some staff who are good but they can’t do all the jobs”.

Staff and people who used the service described incidents of conflict that had repeatedly occurred between the registered manager and the previous deputy manager in communal areas of the service. The provider was aware of these conflicts but had not taken effective action to address this situation prior to the deputy managers resignation.

Staff had lost confidence that concerns they reported would be investigated. Staff described how they had been ‘punished’ and ‘discriminated’ against by other staff, who had refused to respond to requests for assistance, after raising safety concerns with the registered manager. This meant people using the service and the staff members, were exposed unnecessarily to risk of harm. Staff who raised safety concerns during the assessment were fearful of retaliation and one staff member asked, “Please keep me safe as [the manager] will make my life bad if [they] knew what I had said”.

The provider had systems in place to enable staff to report concerns to senior managers when needed. Staff told us this system had not worked as intended and action had not been taken to address concerns they had reported to the provider’s human resources team. In addition, when an external training provider had raised a complaint, following information shared by staff during a course, this complaint had not been robustly investigated by the provider. The provider did not have effective systems to ensure safety concerns and complaints were fully investigated. This contributed to a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff told us they were discriminated against based on their nationality. Staff reported that different nationalities were treated differently, with some nationalities allowed to work together and others not. Staff comments included, “It is very true, they never seem to put certain nationalities together while other nationalities can, I don’t know why” and “The seniors said we are not allowed to work together”. The registered manager was aware of this situation and told us the restrictions had been introduced to prevent staff using languages other than English. However, these restrictions had not been consistently or fairly applied to all staff groups.

The provider’s systems to protect people and staff from discrimination were ineffective. Staff had been discriminated against based on their nationality and the culture of the service was not inclusive.

Different staff groups had different experiences in relation to the registered manager. Records showed all staff had received regular supervision and some staff felt well supported. However, others did not feel listened to and that their concerns in relation to the service’s performance had been minimized and dismissed. They told us, “I did tell the manager but I have given up, nothing happened”, “[The registered manager] never sees the other side, what the carers are doing” and “If I go to [The registered manager] with things, they don’t really get sorted”. People also raised concerns about the registered manager’s approach. Comments received included, “I have not told the manager, I don’t think [they] would listen, they are in their little bubble and don’t see what is happening on the shop floor” and “The manager is ok, but you don’t stand in front of the lounge and shout at your staff”. Staff reported the service was infrequently visited by senior managers, who had limited interactions with the staff team. One staff member commented, “I have not seen senior managers visit. [The registered manager] goes to see them. There was an area manager, but I think they have resigned now as well”. Following the assessment visit the registered manager resigned from their role. The provider made prompt arrangements for a manager from another service to support the staff team and a recruitment process for a new registered manager was launched. In addition, in the period immediately after the assessment visit the provider’s directors and senior staff were routinely present, providing leadership to the staff team, engaging positively with visiting professionals and monitoring people’s safety.

The provider did not have effective governance systems to monitor the performance of the registered manager and the service. The provider’s intention was for senior manager’s to visit the service regularly, assess people’s safety and monitor the registered manager’s performance. However, records showed that the two most recent bi-monthly audits had been completed remotely . This meant that prior to our assessment the provider did not have an accurate, current understanding of the service’s performance. Records had not been robustly reviewed, incidents of unfair treatment of staff groups had not been identified and the provider had not identified the lack of guidance available on safeguarding procedures. Audits of digital care records had failed to recognise incidents of restraint had occurred and that necessary risk assessments had not been completed. In addition, audit records showed that issues identified during previous audits had not been promptly resolved. On-call arrangements had proved ineffective and staff had failed to seek additional support when a person declined to leave another person’s room overnight. The provider was aware of conflict between the registered manager and the previous deputy manager, but action had not been taken to address this issue. In addition, investigations into complaints were ineffective and opportunities for learning and to identify incidents of poor practice had been missed. Notifications submitted to the commission had not been entirely accurate. Recommendations made previously, in relation to the use of ‘As required’ medications had not been acted upon. The provider governance systems were ineffective. This was a breach of regulation 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Relatives were complimentary of the service’s communication and told us, “They are quick to communicate with you if anything happens”. Following feedback from the assessment visit, the provider wrote to people and their relatives to inform them of the steps being taken by the provider and the local partners to ensure people’s safety.

The registered manager engaged regularly with health service partners and shared information promptly when changes in people's needs were identified.

Professionals reported they had some concerns about the quality of communication with some staff and that information and advice they shared was not always fully understood. Professionals’ comments included, “Communication with the staff can be difficult and a couple of patients have said they struggle with communication”.

The service engaged with local health partners and there were systems in place to enable information about observed changes in people's presentations to be shared promptly when necessary. Following the assessment the provider engaged positively with local authority and NHS partner organisations to ensure the safety of people living at St Petroc’s. Based on information provided during feedback an action plan was developed by the provider, detailing immediate changes within the service and this plan was shared with the commission and partners.

The registered manager was aware of issues in relation to the quality and accuracy of record keeping in the service. Records of team meetings showed this issue had been repeatedly discussed but not resolved. The registered manager told us, “We have been trying to improve but it’s an uphill battle”.

The service did not have robust or effective quality assurance systems. Care records were inaccurate and incidents had not been highlighted to the provider for investigation. This meant opportunities for learning and improvement had been missed. The provider demonstrated some innovation and had a purchased a house to provide accommodation for overseas staff when they initially arrived in the area. Staff appreciated this and the support they had received from the registered manager.