CQC report explained · a nursing home
What the CQC found at Crann Mor Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2020
Crann Mor Nursing Home is rated Good overall; inspectors found kind, safe care, but leadership and quality checks need improvement.
Inspectors made an unannounced visit over 17 and 18 December 2019. They spoke with people living at the home, relatives, staff and a visiting professional. They also observed care and checked care records, medicines, recruitment, training, complaints, incidents and audits.
People were generally safe and well cared for. There were enough staff, medicines were given as prescribed, the home was clean, and people had access to healthcare. Staff were described as kind and respectful, and care plans reflected people's needs, choices and interests.
The main weaknesses were in the home's management and checking systems. Water temperatures were not checked at every outlet, some radiators were uncovered without a risk assessment, three legal notifications had not been sent to CQC, and some staff employment gaps had not been explored.
The overall rating remained Good, as did Safe, Effective, Caring and Responsive. Well-led fell from Good at the previous inspection in May 2017 to Requires Improvement because management checks had not found all the problems.
Kind and respectful staff
People and relatives described staff as kind and caring. Inspectors saw warm relationships and heard laughter and good-humoured conversation.
“People were cared for by staff who were kind and compassionate.” from the report
People felt safe
People said they felt safe, and inspectors found safeguarding systems, staff training and suitable staffing levels.
“There were effective safeguarding systems in place. Staff knew how to identify abuse and were aware of how to report it.” from the report
Personalised care
Care plans included people's needs, likes and dislikes. Staff involved people and relatives in reviews and updated plans when needs changed.
“Everyone had a detailed and person-centred care plan which gave information about their needs, their likes and dislikes.” from the report
Good healthcare support
People were helped to access a range of health professionals. Staff also monitored people's weight and acted when someone was at risk of malnutrition.
“Records showed people accessed the dentist, GP, speech and language therapy, chiropodist, optician and the mental health team where required.” from the report
Water safety checks
needs fixingWater temperatures were checked in communal areas but not at every water outlet. The provider said regular checks would be put in place.
“However, these were not being checked at all of the water outlets, to ensure they remained within a safe range.” from the report
Incomplete environmental risk assessments
needs fixingThere was no overarching assessment of the risk of legionella developing. Some radiators were uncovered and there was no assessment of the risk from people touching them.
“Most of the radiators in the home were covered, however some were not. Whilst the lead nurse reassured us there was no immediate risk to people, there was no risk assessment in place to confirm this.” from the report
Weak management checks
needs fixingThe home's audits covered most areas but did not identify several of the problems found by inspectors. This led to the Well-led rating falling to Requires Improvement.
“Although these covered most aspects of the home, they had not ensured water temperatures were being taken regularly, staff gaps in employment were being fully explored and the risk to legionella had been assessed and mitigated.” from the report
Missed legal notifications
needs fixingThe provider had not told CQC about three Deprivation of Liberty Safeguards notifications. These were completed during the inspection.
“The provider had not notified us of three Deprivation of Liberty Safeguards notifications in line with their legal responsibilities.” from the report
Recruitment records
minorTwo staff files had unexplored gaps in employment history. The provider said these gaps would be checked and recorded.
“The two staff files we reviewed had unexplored gaps in employment history.” from the report
- 01Have you now checked and recorded water temperatures at every water outlet, including bedroom taps?
- 02What risk assessment is now in place for the uncovered radiators?
- 03What action has been taken to assess and reduce the risk of legionella?
- 04How do your audits now make sure that problems are found and followed up?
- 05Have all staff employment gaps been explored and recorded, and how are consent and capacity assessments checked?
This was an unannounced inspection of the care home covering all five CQC questions, including both the premises and the care provided. This explanation was written from the published report of 21 January 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, April 2017
Rated Good; inspectors found safe, kind and responsive care, with improvements made after concerns at the previous inspection.
This was an unannounced inspection on 11 April 2017. Inspectors spoke with six people, three staff members, four relatives and the registered manager. They reviewed care plans, medicine records, risk assessments, accident records, complaints records, staff files and audits.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines management, suitable recruitment checks and staff who understood people's needs. People were supported with food, healthcare, personal choices and activities.
Inspectors found that the home had improved since April 2016. Previous concerns about the environment, people's support with eating, the Mental Capacity Act, personalised care and quality monitoring had been addressed. The report also noted two small record-keeping issues that were discussed with the management.
Enough staff
Inspectors found that staffing levels allowed people's assessed needs to be met and that staff responded quickly when people asked for help.
“There were enough staff to ensure that people's assessed needs could be met.” from the report
Kind and respectful care
Staff knew people well, used their preferred names and supported privacy, dignity and independence.
“People were treated with kindness and compassion in their day-to-day care.” from the report
Personalised care
Care plans recorded people's routines, preferences, communication needs and interests. Staff were able to describe how they would support people.
“Care plans were person-centred and reflected people's individual needs, communication, behaviours, preferences and goals.” from the report
Safe medicines
Medicines were administered, recorded and stored safely. Records showed people received medicines as prescribed.
“Medicines were administered, recorded and stored safely.” from the report
Improvement after the last inspection
The home had addressed the breaches and concerns found during the April 2016 inspection.
“At this inspection we found actions had been taken to ensure the Regulations had been met and the home had improved.” from the report
Lunch alternatives were not recorded
minorThe lunch menu did not record an alternative meal, although inspectors saw an alternative being provided. The manager said alternatives would be added to the menu.
“an alternative meal was not recorded on the menu for lunch.” from the report
Accident records lacked an actions section
needs fixingAccident records did not have space to record actions taken to reduce the chance of a repeat accident. This was discussed with the manager.
“there was not space to record any actions taken to minimise a repeat of such accidents.” from the report
- 01How are actions after accidents recorded now, and how do you check that lessons have been acted on?
- 02Is every lunchtime alternative recorded on the menu, including alternatives for people with dietary needs or preferences?
- 03How will you involve residents and relatives in meetings and decisions about how the home is run?
- 04How are people's care plans reviewed with them and their relatives, and how are changes shared with staff?
- 05What improvements have been made since the April 2016 inspection, and how are they being monitored?
This was an unannounced comprehensive inspection covering all five questions and checking whether improvements from the April 2016 inspection had been made. This explanation was written from the published report of 29 April 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Crann Mor Nursing Home
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- January 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2014
Registered with the Care Quality Commission on 10 October 2014.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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