Cressington Court Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed 6 quality statements in the safe key question and found areas of significant concern. The scores for these areas have been combined with scores based on the rating from the last inspection, which was requires improvement. Our rating for this key question has changed to inadequate. We identified two breaches of the legal regulations. The provider did not consistently assess, monitor and mitigate the risks to people's health and safety. People were exposed to a risk of harm as their individual risk assessments did not include the necessary information to keep them safe. The provider did not operate effective systems to ensure people were protected from abuse and improper treatment. We found allegations of abuse were inconsistently shared with the local authority safeguarding team. This meant concerns were not subject to the right level of scrutiny and increased the risk of abuse re-ocurring. Safety related themes and trends were not identified, recorded or analysed reliably. We found the provider failed to act upon known risks which exposed people to an ongoing risk of harm. The provider failed to operate effective systems to ensure staff were safely recruited and ensure they received training to equip them to carry out their roles safely. Training records showed not all staff had received training in essential areas such as infection control, person centred care and diet, nutrition and hydration. People were at risk because the systems in place to prevent and control the spread of infection were inadequate. Processes were not established to ensure equipment was routinely cleaned as no cleaning schedules had been implemented by the provider. Medicines administration records (MAR) did not always show people were supported to take their medicines safely. Several peoples MAR's contained missing signatures and therefore the records did not always assure us people had received their medicines as prescribed.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People experienced poor outcomes as the provider failed to learn lessons and act upon known risks. For example, three people told us they often felt too warm in the environment. The concern with environmental temperatures was identified at the previous inspection and we outlined that improvements were required. However, the provider had failed to implement effective measures to ensure these concerns were acted upon. Concerns people raised were not always listened to and acted upon. For example, a person told us about their ongoing discomfort with a piece of equipment. Despite raising this several times with the provider, they told us no action was taken to improve their comfortability and reduce risks associated with skin integrity.

There was an overall culture of staff being afraid to raise concerns. Staff told us they did not always feel they could raise issues or concerns with the provider and some staff told us they were worried about their jobs as they could be seen as "troublemakers". Comments included, "I don’t really raise things, it worries me to raise things" and when speaking about risks associated with staffing, a staff member told us, "I am worried about raising this." The provider described how they had learnt lessons from inspections previously carried out and had acted upon areas that required improvement. However, there was little evidence this learning had been applied in practice and continued breaches of the legal regulations were found.

The provider failed to embed an effective learning culture. The provider did not look for safety related themes and trends reliably and robustly. Incidents were either not recorded, not investigated thoroughly or not investigated in a timely manner. For example, we found 14 incidents that occurred in February 2024 that were missing from the providers overall incident log and analysis and therefore, there was no evidence an effective analysis had taken place. We found incidents that occurred between November 2023 and January 2024 were not analysed until February 2024. The lack of timely action to identify trends and implement measures to mitigate risk placed people at risk of similar incidents re-occurring and increased the risk of avoidable harm. The provider failed to act upon known risks. For example, at the previous inspection concerns were shared about the excessive temperatures across the building which impacted on people's health and safety. Despite developing an action plan to address this concern, we found the provider had failed to implement an effective system as daily temperature charts were not maintained for 9 bedrooms and thermometers were not available in some areas for several months.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Overall, people told us they felt safe living at Cressington Court Care Home and described how staff treated them well. Comments included, "Yes, overwhelmingly safe” and "There are people around you all the time that makes me feel safe.”

Staff demonstrated a good knowledge of safeguarding processes and could describe the action they would take if they felt someone was being abused. A staff member told us, "I would call the safeguarding team and report it." The manager was able to describe the process they needed to follow to report potential abuse to the local authority safeguarding team. However, we found not all safeguarding referrals were made when required. When we raised this with the provider, they were unable to offer an explanation for these shortfalls.

Our observations found staff did not always act appropriately to safeguard people from potential harm. For example, we observed a person not being supported safely with a piece of equipment and we observed several people who had risks associated with their nutrition not being supported effectively at meal times.

The provider failed to operate effective safeguarding systems and people’s rights to live in safety, free from avoidable harm and neglect were not protected. Records showed safeguarding referrals were not always made to the local authority safeguarding team when required. For example, three safeguarding incidents that occurred in February 2024 had not been shared. This meant allegations of abuse had not had the right level of scrutiny or been subject to an appropriate investigation. In addition, safeguarding records were not well maintained as they were incomplete and lacked detail about the incidents which occurred, and the action taken. The lack of robust records meant there was ineffective oversight of the risk posed to people living at the home. This increased the likelihood of people being exposed to a risk of avoidable harm and potential abuse. Staff training records were not well maintained and we were not assured all staff were up to date in safeguarding training and practice. The training records did not show that staff were scheduled to update their safeguarding knowledge yearly as recommended in health and social care best practice guidance.

People expressed they were generally happy with their care and told us they felt safe. However, a person told us they had raised concerns about a piece of equipment and the impact this was having on their health and comfort. We found no action had been taken into response to this persons concerns.

Information about risks to people’s safety was not always communicated to staff. Staff told us people's individual risk assessments lacked the detail needed to guide them on how to keep people safe. A staff member told us, “When they bring new people in, we are not getting time to know them or do assessments. I feel I am not doing a good job and it is not safe. People just keep coming in.” Another staff member told us, “There is not enough about people. I literally do not know how the likes of the agency workers cope in here.” The provider accepted essential information about peoples care and support needs were missing from the care planning system.

Our observations found risk was not effectively managed and we found people were exposed to risk which was avoidable. For 2people, we identified safety related concerns with equipment and for several people we observed nutritional risks were not effectively managed.

People were exposed to risk of harm as their care needs and associated risks had not been managed appropriately. People's individual care plans had not been completed for areas of potential risk and lacked essential information to guide staff on how to manage people's individual risks. For example, a person who was at risk of choking did not have a choking risk assessment in place and another person who required a modified diet was not receiving this placing them at risk of harm. In addition, we found effective support was not provided to several people who were at risk of weight loss as risk was not effectively monitored and there was a lack of action taken to share the concerns with the relevant health professionals. People's risks were not routinely reviewed. The majority of care plan review records were blank. The lack of effective reviews meant the provider failed to identify when records were not reflective of people's current needs and risks.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us there were enough staff around when they needed them. Comments included, "Never had any problems, they are about when I need them and have attended quickly when I’ve used the bell in my room” and “I like being in my room most of the time but they do come and see if I’m ok and come if I call them."

Staff told us they did not feel the staffing numbers were always sufficient and they felt people's needs were not being consistently met. Comments included, "The residents don’t always get what they need" and "The staff here are just burnt out." Staff also described how they often felt rushed and did not have the time to talk to people. A staff member told us, "It would be nice to get to sit and chat to the residents. This is something we just don’t have time to do.”

Our observations found there were enough staff available to support people with basic elements of care. However, staff were observed to be rushed and were task focused in their approach to care. We observed people waiting to be helped, and there was a hurried and chaotic feel to care delivery. Our observations found that staff were unfamiliar with people's known risks. For example, our observations at meal times identified staff lacked the essential knowledge of people's nutritional risks and we observed several people who were not supported effectively in this area.

The provider failed to operate effective systems to ensure staff were recruited safely. For example, we did not find evidence a staff members right to work check had been completed. For another staff who had restrictions in place as part of their visa, we found this was not explored by the provider. In addition, induction records did not assure us all staff had received an effective induction when they first began their employment. The systems in place to ensure staff received training the provider considered mandatory was not effective. Training records showed not all staff had received training in essential areas such as infection control, person centred care and nutrition and hydration. The provider had taken action to improve this area as records showed training shortfalls had been discussed at staff meetings and some effort had been made to enrol staff onto the relevant training courses.

People told us they were happy with the cleanliness of their home. They told us the environment was kept clean and hygienic and staff followed good hygiene practices. Comments included, "Yes, they keep it clean. Clean round my room each day and empty bins” and "My room is cleaned every day.”

Staff told us the home was maintained to a good standard and was always kept clean and tidy. They told us a supply of PPE was always available to use. The provider did not assure us appropriate measures were in place to ensure infection prevention and control practices were robust. There had been some recent outbreaks of healthcare associated infections and, despite telling us a deep clean had taken place, we found no evidence to support this.

Our observations found communal areas were mostly clean and hygienic. However, we observed items of dirty equipment on both floors of the home and continence aids stored inappropriately. This was despite similar concerns being raised previously by visiting infection control professionals. We found staff did not always use PPE effectively to mitigate the risk of infection spread. For example, we observed a staff member failing to change their PPE when assisting multiple people including assisting one person with their continence needs. PPE was not always disposed of safely as we found a total of 10 used disposable gloves littered around the rear garden.

People were at risk because the systems and processes in place to prevent and control the spread of infection were inadequate. Processes were not established to ensure equipment was routinely cleaned as no cleaning schedules had been implemented by the provider. Our observations found cleanliness concerns with multiple pieces of equipment. This included wheelchairs, weighing scales and chairs which were frequently used by people living in the home. There was a lack of robust auditing in relation to infection prevention and control as we found only 1 audit had been completed in February 2024. This was despite multiple infectious outbreaks occurring within previous months. The audits failed to identify all concerns found during the assessment which included the lack of cleaning checklists for equipment and the inappropriate storage of continence aids on floors. Opportunities were missed to improve the safety of the service and protect people from the risk of infection spread.

People were generally happy with the support they received with their medicines and told us they received their medicines when they need them. Comments included, "They know when to give them to me and that’s when I get them” and "They tell me what they’re giving me.” Our observations found medicines were stored safely as medicines trolleys were kept locked when unattended.

Staff who were responsible for administering medicines told us they had received training and their competence to safely administer medicines was assessed.

Medicines administration records (MAR) did not always show people were supported to take their medicines safely. Several peoples MAR contained missing signatures and therefore the records did not always assure us people had received their medicines as prescribed. When people required medicines on an 'as and when required' basis to help manage periods of emotional distress, care plans did not contain sufficient information to guide staff on what measures should be tried first to avoid the overuse of medicines with a sedative effect. A person's MAR showed frequent use of this type of medicine. However, the provider had not taken any action to escalate the increased use of this medicine to Mental Health professionals involved in the person's care or their GP. Through their auditing processes, the provider had identified some shortfalls with medicines management and an action plan was in place to ensure remedial action was carried out to improve safety.