Creedy House

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 management team told us that they and the service were looking at ways to continually improve. Accident, incidents, complaints or other significant events were logged on an electronic system. The management team used this to analyse trends and patterns, this analysis had not always been fully robust as times of day had not been identified for some incidents and accidents and part of the documentation was missing. Systems and processes to audit and check the service were in place, however these were not always robust. This evidenced that the legal requirement in relation to good governance had not been met.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The management team were clear they wanted to improve the service and outcomes for people. The staff gave mixed feedback about the culture of the service. Some staff reported a positive open culture where they felt empowered to raise any concerns or make suggestions. Other staff gave negative feedback. Comments included, “I would only raise concerns as I'm leaving to go to another job, trust me it's just not worth it as nothing will change anyway. Good practice guidance is readily available at Creedy House but it's not worth the read as actions speak louder than words.” Staff told us there were meetings they could attend. A staff member said, “We have team meetings and they give notice about these and send emails. If I don’t go, I can read the minutes of the meeting from the notice board. There is good communication.” Another staff member told us, “You can make suggestions, but these often fall on deaf ears. For those that can’t attend [meetings] then matters covered are available to read.”

The provider and the manager had kept up to date with local and national developments within health and social care and had attended forums, training and signed up to well known, reputable websites to find advice and guidance such as Skills for Care. Skills for Care supports adult social care employers to deliver what the people they support need and what commissioners and regulators expect. The registered manager used opportunities to gather feedback from people, relatives and staff. There were regular meetings with all groups of people and participation and comments were encouraged. A person told us they had been to meetings, “I’ve been to 2-3 in the past. They ask us if we are happy here, about the staff.” Handover meetings were held daily and documented.

The management team knew people well and were passionate about making sure people received good quality care. The registered manager told us, “We are an established team, very caring, I have no undue concerns, the staff team are a cheerful bunch, the relatives are happy and when they become bereaved, they still come and visit us and get involved because they have got to know us and the residents over the years. There was a clear management structure in place with 2 registered managers, one of whom was the deputy manager. Nurses provided clinical support to people and they were supported by senior care workers and care workers to provide care and support. Staff understood their responsibilities to meet regulatory requirements. The registered manager was supported by the provider and an operations manager visited the service regularly to undertake checks and audits. The management team told us they were well supported by the provider.

The registered manager carried out a number of checks and audits in the service, some of these were not documented so they were hard to evidence. For example, daily walk around to do observations of practice were not recorded. The registered manager sent a weekly report to the nominated individual for the provider. An outside contractor visited the service each month. The action plan of things that needed to be done as an outcome of observations, audits and checks were not always written down. The registered manager told us these were “Mainly in my head, I do write lists in my diary and tick them off.” This meant that actions and items could be missed and forgotten and that the wider management team may not be aware of all the actions/issues and concerns. The registered manager told us actions from previous reports and action plans were recorded on the provider report and that the maintenance plan had clear actions.

Staff confirmed they were invited to meetings and encouraged to contribute. However, they did not always feel listened to. Staff meeting minutes evidenced that these took place regularly. Some staff told us they were encouraged to voice their ideas for improvements and any concerns. Staff knew how to raise concerns with the provider or outside organisations if they needed to. Staff said, “We have staff meetings every couple of months, and we can give suggestions and raise concerns and appropriate actions has been taken to tackle the issues and make the workplace better and safer” and “I absolutely do not feel able to share concerns with the management, unless I want the world and his wife to know. You can share concerns anonymously (which is the wisest choice) but don't hold your breath.”

The provider had systems and processes in place to foster a positive culture where people felt that they could speak up and have their voices heard. Complaints processes were available. A person told us, “I only have to go to [registered manager] or [administrator] in the office and they will help me. [Registered manager] is a caring person, she gets involved and helps at mealtimes too. I've only had to talk about my room, when I was on the ground floor and [registered manager] took care of everything.” Relatives told us, “I have no complaints” and “Never had to (complain) but would be happy to do so. I would go to the manager, but it would depend on the nature of the concern.”

Staff gave us mixed feedback about whether they were treated fairly and equally by managers and their colleagues. Comments included, “I don’t feel supported in my role, you just have to get on with it and be quiet” and “I can tell [registered manager] anything and she’s really supportive.” Another staff member told us there were unhealthy relationships between nursing staff and care staff and they felt there was a blame culture. They gave examples of this happening for example, nursing staff challenging why people were not showered on certain days and not listening to care staff reporting that people had declined a shower. The provider deployed a diverse workforce and encouraged a culture of teamwork, respect and cooperation. Some staff reported there was a reoccurring problem of staff who did not speak English as a first language talking in their own language in front of people and other staff. Staff told us the management team had addressed this a number of times. We observed there were signs up in staff areas around the service reminding staff to only talk in English when at the service as all people living at the service spoke English. Many people living at the service lived with dementia and speaking in different languages around them could cause them to become confused and agitated. Staff were supported if they had any personal issues affecting their work. The registered manager felt supported in their role and had support from other manager's on the day of the assessment. The registered manager told us they carried out regular observations of practice, these were not documented.

The provider had processes and policies in place to encourage an inclusive culture. However, not all staff felt the culture of the service was open and inclusive. Some staff reported the staff all worked together well as a team. Some staff reported that this did not work so well. They gave examples of where there were areas for improvement in working between nursing staff and care staff. Such as nursing staff not supporting care staff to provide personal care to help get people washed and dressed and ready for their day when their nursing duties such as medicines administration and wound care had been completed. The provider had a statement of purpose in place which laid out how they would meet people's care and support needs as well as what people could expect from the provider and the staff who will support them. They provider was not fully achieveing their aims and objectives - as we had identified within this assessmenbt breaches of regulation and areas for improvement. The workforce was diverse and support was in place for staff. Staff were invited to meetings on a regular basis. For those unable to attend the meeting records were available to them.

Some staff said the management team were supportive and approachable. Other staff were not positive about the management team and working relationships. Some staff we spoke with were confident that they could discuss any concerns with the management team and these would be acted on, they were aware of how to escalate concerns to senior management or outside of the organisation. Some staff were not confident they could report things. Despite the mixed comments, staff told us they liked working in the service. Staff said, “The best thing about working here is the familiarity of the staff team and the residents”; “I think the best thing about working here is the ability to raise concerns when we need to. It’s a good place to work and I enjoy coming to work because people are hardworking and supportive and there are enough staff”; “The best thing about working here is knowing that you have done everything within your power to allow the residents day to be the best you can gift. And most staff members at Creedy House are fantastic.” The registered manager told us, "We meet weekly as management team and link with other managers in other homes for buddy and peer support."

The provider had systems in place to check the quality of the service. Audits had been carried out. There were monthly audits of infection control, care plans, medicines, kitchen, weights, falls and wounds, incidents and accidents, training, supervision, complaints and maintenance until August 2024. Records showed no monthly auditing had taken place in September 2024. The registered manager told us this was because the audits for September had not taken place at the time of our assessment. The audits were not robust enough to highlight and manage shortfalls in the service. For example, the training audits had not detailed that staff had not completed appropriate training to meet people’s assessed needs. The care plan audits had not detected that people’s specific health needs had not been included. The monthly audits carried out by an external person on behalf of the provider had been carried out regularly. Actions had been recorded and the management team had signed off items that had been addressed. The monthly audits had not detected the issues we found at the assessment visit. Services providing health and social care to people are required to inform the CQC of important events that happen in the service. This is so we can check that appropriate action has been taken. We were assured that all incidents had been appropriately reported. People's personal records were stored securely including on computers and applications on devices, these were protected by passwords, so that only staff who had been authorised to access the information could do so.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.