Marcris House

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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 assessed all 7 quality statements in the well-led key question. We found poorly operated systems by the registered manager and provider led to a lack of governance and oversight. The management team completed some audits, but most required audits were not completed. The provider and registered manager did not provide support and direction to staff to develop an open, honest, reflective culture within the service. Staff understood their role and responsibilities but found it difficult to complete all expectations due to the lack of staff and effective leadership. Managers did not work with their staff or partners to develop ideas and innovation to improve the quality of care provided. Managers did not demonstrate they were inclusive leaders at all levels who understand how to deliver care, treatment and support that embodies the culture and values of their workforce and organisation. Managers did not have the skills, knowledge, or credibility to lead effectively. People did not experience care from managers who demonstrated integrity. None of the significant concerns found at this assessment had been identified by the providers monitoring, oversight and visits to the service. This is a breach of regulation.

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.

Staff were unable to share the strategy of the service or their understanding of what the culture was like. We received minimal depth in responses from staff such as “Looks good right now” and “All ok.” However, one staff member said, "Overall working at this care home was shocking. The way I got treated and made to feel on a daily basis was unacceptable. The [registered] manager was very rude and made you feel on edge. I got made to feel as if I couldn’t speak to them about any problems or issues because I’d always receive a huge reaction or the blame. I got shouted at sometimes even swore at. And I know that it was like that for many other staff. Even resulting in some staff crying. I did not feel safe here and felt like I could never be myself as I was never sure what reaction I’d receive. I did not feel valued as a member of staff at all." The provider told us there was not an organisational approach to culture and shared direction. They said that Marcris House was not like their other registered care homes, and they did not understand why the issues in the service arose. They told us they relied on their managers to embed a positive working culture in the home and agreed that not embedding their visions and values and monitoring those had contributed to the development of a closed culture in Marcris House. They said there was not shared learning among the team, and the registered manager had not operated the service in an open and transparent manner which was free from blame.

The provider and registered manager did not create a shared culture of positive care or a working environment based on transparency, inclusion and engagement. The provider was not able to provide us with an overview of their ethos or values. We have reported elsewhere within this assessment that the wider systems, and leadership across the organisation did not demonstrate a good understanding of the values needed to embed a strong positive culture that challenged poor practise and ensured all staff worked towards the same outcome for people. The provider had not prioritised safe and compassionate care. There was a poor-quality culture at the service. This is because low staffing levels meant that people’s preferences, and dignity was not always supported and people were not kept safe from harm. The environment was not well maintained. Peoples rooms and communal areas were not clean and people were at risk of acquiring infections. People were not supported through systems designed to keep them involved and respond promptly when their needs changed. People did not live in a home that kept them safe and did not report appropriately when things went wrong. Staff did not have the necessary training to provide good, positive support and challenge poor care and a poor culture. People were not consulted when decisions were made that affected them and their liberty. People were not able to engage in meaningful activity or discussions to support their wellbeing and interests. The overall culture within the service did not support good outcomes for people and represented a closed culture. Staff were not empowered to work with confidence and autonomy. Management failed to identify through a system of governance the significant failings in the service. Staff were not kept informed of developments and the provider did not act in an open and honest manner. These areas among others reported were not effective at creating a good culture.

Due to recent changes in management and leadership at the service, staff were unclear in their feedback and were guarded when offering their views. However, one member of staff told us, “In the past in my experience, organisation of the office was not what it should be and previously when I suggested archiving, updating files etc., and spending some money on various things, this was met with an unhelpful response.” The director told us on 23 July 2024 that staff had approached her and raised concerns around the conduct of the previous registered manager, suggesting they took control of everything within the home and had deskilled the staff. The director told us in her opinion, the registered manager had deskilled staff and had negatively impacted their confidence. They told is that supervisions had not happened to support staff, and the registered manager had not had supervision in over 2 years. They said that there was not an inclusive and open relationship between staff in the home and that morale was low. The provider acknowledged the wider failings in the service. We asked the nominated individual during a Teams call discussion why these critical checks were not in place. He told us, “I rely on the manager to do their job, and I think we relied on them too much and now we can see what has happened and people haven’t been kept safe have they?”

Managers at all levels including the provider and director overseeing Marcris House did not recognise poor care or act when they did identify this. The director told us they had noticed performance issues with the registered manager prior to their resigning but did not feel able to formally challenge them. We also observed a staff member grab a person’s cardigan sleeve to encourage the from the chair. The person did not want to move but the staff member insisted. We reported this to the director who spoke with the staff member but did not impose any observation, retraining, supervision etc. Managers at all levels did not have skills, knowledge, and credibility to lead effectively. The senior management team collectively did not act in a manner which mirrored their view of a positive culture of care. Staff had little opportunities to speak to the management team, team meetings were not held, and information was passed through 10 minute daily handovers. Systems to openly learn from incidents and discuss with staff were not in place. Staff did not raise concerns outside of themselves and not with external agencies The registered manager received the same training as the care staff with no leadership training, diversity, inclusion, supervision etc. The director responsible for auditing the service had no experience, or training of both care and management and oversight. They relied at times on another home manager to support them with audits. This meant the wider leadership team did not have the ability to instil and drive a positive culture of care and value their workforce.

Staff told us they felt able to speak up at the service. One staff member told us, “Yes, I can tell someone. The owner is very nice.” Another staff member told us, “I do feel able to speak up at work, perhaps more so now and have done so. I am aware of the whistleblowing service.” However, we found numerous examples where staff did not. For example, cleanliness, maintenance, safety, staffing, safeguarding concerns. One staff member anonymously told us they felt they could not approach the manager for fear of repercussions. Staff said they felt the previous registered manager disempowered them and did not lead them as a team to perform well. We found that since the departure of the registered manager, staff had been willing to speak up to the provider and director, along with visiting professionals about their concerns, experiences and feelings of working in Marcris House. However we have referred to this in the processes section of the report below that the involvement of the provider, after the departure of the registered manager, did not stop a closed culture developing.

The registered manager had not received supervision for 2 years and felt overwhelmed with current workload and developments. They had not raised this to the provider. They also did not raise concerns externally to agencies or CQC. Collectively, by not raising concerns and speaking up enabled the development of a closed culture to envelop Marcris House. The provider could not demonstrate how they encouraged staff to speak up. We were not provided with the systems the provider used to support a positive culture. For example, team meeting minutes did not demonstrate a safe space to voice concerns. Policies and processes were not in place to monitor the positive culture in the service. This led to an environment where staff were stressed, tired, overworked. A staff survey had been completed in 2022 but not since and opportunities to engage with staff meaningfully to understand the culture since the manager resigned had not been undertaken. The director overseeing the day to day management told us that some staff had approached them to talk about the low morale in the surface, feelings of overwork and not feeling valued. Although staff had begun to raise concerns, the systems operated by the provider did not promote a speak-up culture which values and encourages open and honest communication. The provider and registered manager had not provided a safe, non-judgmental place for staff to share ideas, report concerns or confidently voice opinions. This meant a actions were not taken that could have been taken earlier to improve the closed culture experienced by all living and working in Marcris House.

The provider told us they employed a diverse workforce with people employed from a wide range of backgrounds, cultures and experiences. Some staff said they were treated well by the previous registered manager. They said the previous manager was supportive and offered them opportunities. Other staff however, felt that the management team were not supportive, were oppressive and did not offer opportunities to all staff. The provider who was managing the service in the absence of the RM told us staff had begun to approach them and expressed how they gradually had been given less and less opportunity, that the manager increasingly became absent and spent more time in their office. They told us that staff had reported to them that the previous manager assumed control across all areas and did not offer equal opportunity and chances to staff. They said staff had increasingly not been part of an equal and inclusive culture, did not all feel valued or empowered to work autonomously and free from blame. We asked whether the provider could demonstrate organisational examples of how they develop and support a compassionate, collaborative and inclusive culture for all staff, but they did not provide us with a verbal explanation or any evidence of this in place across the wider operational group.

The provider had not developed a workforce that was inclusive, supportive and adopted a fair culture. The provider told us they employed a diverse workforce with people employed from a wide range of backgrounds, cultures and experiences. However, we were not provided when we requested evidence of clear policies, which encouraged and developed the equality and diversity in the service. Leaders across all levels of the organisation did not use effective ways to evaluate how staff felt, or were aware of the poor quality of care provision.

Due to recent changes in management, staff were not all clear as to the roles and responsibilities of leaders. Staff knowledge about governance and processes in place was limited. One staff member told us, “Manager (is here) 8 to 5 every day, and senior 24 hours. It’s good (management), seniors do everything like walk rounds, guidance. We check everyone every 2 hours and write it on the papers what we did.” The feedback we received from the senior leadership team overseeing day to day management of Marcris House demonstrated a lack of awareness and experience of delivering and overseeing safe systems of care. The provider was quite open when asked about why the governance had failed and told us it was because they trusted their managers and had not had the checks in place, which they now realise meant people were not safe. The provider contacted us after the assessment to inform CQC that following the CQC assessment and actions arising, along with termination of their contract from the local authority, they would be closing Marcris House.

These assessment findings are underpinned by the lack of governance systems operated by the registered manager and provider. The provider was made aware of these concerns from the local authorities visit at the beginning of July 2024. The local authority consistently found no improvement at follow up visits. These are among the areas reported in this assessment. We visited on 22 July 2024 and found ongoing concerns and additional risks to people’s safety. The provider had not developed an action plan and could not evidence how they were making the improvements. The registered manager had left two weeks prior to our visit, yet the nominated individual and management team had no clear plan as to which areas of improvement needed to be prioritised. The management approach was disjointed and chaotic. The provider did not demonstrate an understanding of how to make improvement happen or how to measure outcomes and impact on people. Audits were not effectively in place for areas such as skin integrity, injuries, wounds, safeguarding, fire safety, medicines management and staffing. Where an audit was used these were not comprehensive. Daily observation records were not consistently completed. Safety audits relating to fire drills, evacuations, simulated evacuations, electrical safety checks, water, health and safety, infection prevention and control [IPC] were not made available to us when requested. Management did not support staff to develop and improve the service. Staff meetings had been held, but discussed issues such as ensuring annual leave was taken on time, and not asking for staff ideas and feedback on the delivery of the service. People and relatives feedback was not sought to influence positive changes. The provider had overall failed to implement and operate effective risk management systems and to assess, monitor, and mitigate risks to people and staff.

People were unaware of any partnerships with the service and although they knew agencies such as the GP and emergency practitioner visited the service, they did not see any involvement or engagement from, or with, wider communities.

Staff and senior management said they worked with the GP and Community Matron frequently and referred people to external health specialists for support and guidance when and as their needs changed. However we found numerous examples where this had not consistently happened. In addition to examples reported elsewhere we found instances where staff were not clear on the referral pathways and referred one person who had lost a significant amount of weight to the dietician but through the speech and language therapist [SALT] pathway. The dietician and SALT teams offer different types of support, by sending the referral to the wrong professional led to a delay in these peoples dietary needs being assessed and therefore at greater risk of weight loss.

Feedback about partnership working was variable. The GP surgery and community nursing team said that they worked positively with all staff at Marcris House. They said the manager attended a weekly multi disciplinary meeting MDT meeting and discussed people's changing needs. However they were informed of a number of people who had sustained wounds or concerns regarding nutrition, medicines and falls as a result of this assessment by CQC. The local authority reported that historically the communication and partnership working had been positive. Over the past 12 months they have seen this changed and the manager has been less communicative. Examples given included where the registered manager avoided organising a date to convene their assessment with the local authority. This assessment is used to provide assurance to the local authority that the care provided meets their required contractual standards. Following this assessment the provider did not seek support from the available wider partnerships to immediately respond to the concerns raised and improve the safety and quality of care. The local authority safeguarding team reported that alerts were not raised with them with very little, if any, engagement to understand the risks and work in partnership to improve care. The provider did not use partnership working as a positive step to understand the quality of care provided, and to support the improvements needed. The previous registered manager was not part of wider provider support groups, training and development networks or carer networks. We asked the provider for examples of work carried out in collaboration with others and they were unable to provide us with an example. Other than the GP / Matron, that we established were not always referred to as needs changed, the service did not have any links to support partnership working. This enables a closed culture to develop as there is less external monitoring to help identify and mitigate poor practise.

People did not experience partnership working outside of Marcris House to support their health or social needs consistently. Relatives were encouraged and did visit people in Marcris House, but unless they took them out people did not leave the home for external activity. There were no staff employed to manage engagement within the service, which meant there were not links to outside groups and activities. Little stimulation was provided within the service leading to a lack of a sense of community and inclusion within the home. We observed a number of people with bruising or abrasions to their arms and legs, and could not establish from care records or incident reports when and how these were sustained, or the actions taken to manage those. We asked for all 27 people to have a visual skin assessment which raised a further 9 people with wounds previously not known to the management. These 9 people were then referred to either the community matron or GP for follow up. This demonstrated that the system and arrangements in place did not work in order for people to be referred promptly. Senior care staff were not aware of the referral pathways used and we found an example where this had been incorrectly used referring one person to the wrong service. A second person had three falls within a short period, no referral was made to the GP for review, or the falls clinic / specialist. This person later had a further fall.

Staff could not provide examples of continuous learning, innovation or improvement. The directors told us regarding lessons learned that this is not in place. They told us staff do not discuss, reflect or learn on incidents, injuries, safeguarding, complaints or reflect on their practise or discuss ideas and innovations. The registered manager did not have an improvement plan in use, and only a recently developed action plan was in place which was developed in response to the local authority review of 03 and 04 July 2024. There was no shared service improvement plan, the registered manager was not able to share this with staff to discuss, make suggestions and to keep staff informed of developments within the service. We were provided with one set of meeting minutes from January 2024. We confirmed with the directors overseeing the service that team meetings, supervisions had not been held with staff since that time. They were unable to explain the reason for this, or why this was not identified through provider monitoring. This demonstrates that staff were not given an opportunity to share learning or discuss ideas / innovations. Senior management did not demonstrate a good understanding of identifying improvement and implementing actions to mitigate the risks around the quality of the service.

Feedback from people, staff and the local authority, indicated that learning improvement and innovation was not part of the wider culture of the service or the leadership by the provider. The provider has confirmed that systems to act in an open and honest manner to focus on continuous learning, innovation and improvement across the organisation were not in place. They acknowledged incidents and safeguarding was an area that the management had not used to learn from with staff. They also said as meetings and supervisions were not held staff could not use these forums to develop and learn and discuss innovation. Senior managers did not demonstrate a good understanding of identifying and actioning continuous improvement in the quality of the service. There was no overarching improvement plan to address the significant concerns found. Audits completed were not accurate, or were not completed so did not inform wider improvements. There had been very little improvement from the local authority review. People's rooms remained unhygienic, the building was unclean, and required further maintenance. Care plans remained unchanged, incidents continued to not be reported, fire risks remained among a number of other areas identified through this assessment. This demonstrated there was not a culture led by the provider of continuous learning, innovation and improvement across the organisation and the local system. The provider had not demonstrated to us that staff were encouraged to suggest creative ways of delivering equality of experience, outcome and quality of life for people. People's daily experience of living in Marcris House was negatively impacted by the service operating as a closed culture.