Crossways Nursing 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

We identified a breach of regulation in relation to good governance. The provider’s systems had not consistently been used to identify shortfalls and drive improvement in the service. Communication systems were not always robust because records of staff meetings for example, were not always detailed and no actions were recorded. Documentation of some records was of an inconsistent quality. There was limited information about how learning was shared with staff.

Staff told us there was an open culture and they felt valued and respected. They spoke positively about the registered manager and told us they felt listened to. Relatives told us they found the registered manager to be approachable and caring.

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.

Staff spoke highly of the registered manager. Comments included, “He’s okay and he’s friendly. If you’re going to him and asking for help then he’ll always come and help. He is visible, he knows everything” and, “The manager is approachable.” Staff described the culture of the service as, “We like to give high quality, person-centred care. We ensure staff value dignity, respect and privacy all the time.” The registered manager said, “We are small, not posh but we do provide good care.” Not all staff were able to tell us the service’s vison and values.

The provider and staff sought the views of people and their families through surveys, individual conversations and reviews. However, there was no record of any action plans based on feedback received.

Staff described the management team as, “Approachable” and, “Visible.” One staff member said, “He’s supportive. He’s there when we need him and he’s always in the home and we can always call him if he’s not there. He’s always on call.” Another member of staff told us, “We [staff] don’t always expect him at night, but he’s normally here three or four nights a week.”

Staff felt supported, attended regular meetings, and told us they were kept fully updated with all aspects within the service. However, communication systems were not always robust because records of staff meetings for example, were not detailed and no actions were recorded.

The registered manager told us they encouraged staff to speak up if they had concerns about poor care. They said, “We mention it in staff meetings”, but this was not recorded in any of the meeting minutes we saw. Staff knew who to speak to with any concerns about poor care. One staff member said, “I’ve worked here for a long time and if there is a problem I will go to the owner straight away as he resolves things very well.”

The service had policies in place that supported staff in speaking up. Policies included the topics of safeguarding and whistleblowing.

The registered manager said, “We are multi-cultural here. We tolerate zero abuse, no matter where staff come from. We encourage staff to practice their religion, and we respect their cultures. If staff need prayer time for example, we support that. We encourage the residents to take part, some of them are quite interested; 1 member of staff came in wearing her clothes from a function, and the residents liked that.”

Staff told us, “We all get on here, we’re all included.”

Policies and procedures supported diversity and inclusion within the service.

Staff told us the management team were visible and present within the service. Staff told us the registered manager was often still on duty when night staff arrived for their shift. The registered manager said, “I know the care is good here. The staff are trained, they have supervisions. Our resident’s health is good. We have lots of long-term staff and we don’t use agency, so we have good continuity of care. [Deputy manager] looks after people like they are family. She is passionate about what we do here.” Staff were aware of the need to keep people’s records safe.

There was limited oversight of the service. Although regular audits were carried out, action plans were not always in place. When action plans were in place, the provider failed to record what progress had been made in completing actions. The most recent medicines audit had not highlighted issues we noted, there was a “weekly call bell audit” that was carried out monthly. There was a form for fire alarm and automatic door releases/detectors to be checked but this did not highlight the expected frequency. Monthly manual wheelchair inspection check records lacked information such as a serial number. The maintenance plan was a 12-month plan and did not include dates to show if or when issues had been added to the plan. We observed flies in 1 person’s bedroom, that staff were aware of, but the issue had not been resolved. When we walked round the service with the registered manager we pointed out issues such as furniture that needed replacing, stained ceilings, and curtains that were hanging off the curtain rail. Large boxes of PPE were being stored in one person’s bedroom, and nobody had considered this inappropriate.

After the on-site assessment, we asked the registered manager to send us the latest mock inspection report and improvement plan. The improvement plan was limited. There were no dates recorded for when actions should be completed, or the name of the person responsible for completing the action. The provider could not tell us how they monitored the action plan for progress. During our assessment, other issues we raised were addressed immediately or investigated and the deputy and registered manager informed us of actions taken. This included the registered manager confirming with us that a fly screen had been purchased for the bedroom with flies.

We saw the management team were visible. Statutory notifications were made to CQC in line with regulations.

People did not share any concerns about this quality statement and people's records demonstrated they had timely contact with healthcare professionals.

The registered manager told us the service had strong links with the local church. They said, “The church lady comes once a month or so, she will do a service and do one to one if people want it.”

The service had good links with the local commissioning group. The registered manager said, “We have a weekly communication session on Teams which we link into, and we gain valuable learning points and updates to any Government or local authority changes.”

The service had a good relationship with the local GP team. A health professional visited the service weekly to review people if needed. Staff told us they could contact the GP service for advice at other times easily. We sought feedback from health professionals and no concerns were raised about this quality statement. One health professional said, “The staff are experienced people and easy to liaise with.”

People’s care and support records confirmed the service made appropriate contact with a range of health and social care professionals when required and in a timely way.

Staff gave mixed feedback about learning and improvement at the service. Some staff told us they were unaware of any areas for improvement. Other staff said they had been informed. One staff member said, “If we are visited by professionals and they point out something that needs to be improved then management will always include us and keep us informed.”

There was a range of provider led quality assurance audits in place, but records linked with these were of an inconsistent quality. A mock inspection had been carried out in January 2024, but it was unclear how improvement plans were shared with staff. The mock inspection report we looked at had raised issues that were still present at the time of our assessment. The registered manager showed us minutes of staff meetings, but they did not evidence that areas for improvement had been discussed or shared with staff. Instead, the minutes referred to "discussed" but there was no record of what had been discussed.

Documentation of incidents and accidents was of an inconsistent quality, and some forms we looked at had missing information. There was limited information about how learning was shared with staff.

We saw records that showed complaints had been responded to. However, the complaints file did not contain a record of the original complaints which the provider could not be assured about how effective the complaints procedure was. We discussed this with the registered manager who told us they would review the complaints file.

There was oversight and analysis of people’s weight and any weight loss. Clinical areas were well managed and there was good oversight. Advice had been sought when needed.