CQC report explained · a residential care home
What the CQC found at Credenhill Court Rest Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- People felt safe and staffing levels, risk assessments, recruitment checks and infection control were considered suitable. Medicines management needed improvement, including clearer records for topical medicines, better temperature monitoring and more frequent controlled drugs checks.
- Effective?
- Good
- Staff had training and ongoing support. People could choose their food and drink, received support with their health needs, and the home was following the Mental Capacity Act requirements.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. People were supported to express their views, make choices and remain as independent as possible.
- Responsive?
- Good
- Care plans reflected people's individual needs, histories and preferences. People were supported with activities, complaints and end-of-life choices.
- Well-led?
- Good
- The management team was approachable and supportive. Audits and checks had improved, and the home had made significant progress with care records and quality monitoring.
What inspectors found, January 2019
Rated Good overall; inspectors found kind, personalised care, but medicines management still required improvement.
Inspectors made an unannounced visit on 10 January 2019. They spoke with people living at the home, relatives, staff and health and social care professionals. They also observed care and checked care records, medicines, recruitment, complaints and quality checks.
The home was rated Good overall. People were described as safe, well supported and treated with kindness and respect. Care plans were personalised, activities were available, and staff helped people access food, drink and healthcare.
The main weakness was medicines management. Records for creams and ointments were not clear enough. The home also needed better checks of medicine storage temperatures and more frequent checks of controlled drugs. Inspectors did not find anyone who had missed their medicines.
The home had improved since the November 2017 inspection. Earlier concerns about consent and the overall management of the service had been addressed. However, the Safe rating remained Requires Improvement because of the medicines concerns.
Kind and respectful staff
Inspectors saw caring interactions and found that staff knew people well. People were treated sensitively and their privacy, dignity and choices were respected.
“Staff treated people with kindness and compassion, and had taken the time to get to know people well as individuals.” from the report
Personalised care
Care plans included people's histories, interests and care needs. Staff could read them and use them to guide support.
“People's care plans were individual to them and included information about their personal histories and interests, alongside guidance for staff on how to meet their needs.” from the report
Activities and community links
People could take part in varied activities and pursue personal interests. The home also worked with local groups and community organisations.
“The provider placed a clear emphasis on ensuring people had support to pursue their interests and participate in a variety of stimulating recreational and social activities.” from the report
Improved management
The home had acted on earlier concerns about consent, records and quality checks. Staff and relatives described management as approachable and supportive.
“At this inspection, we found the provider was now meeting the requirements of Regulation 17.” from the report
Medicine records and checks
needs fixingStaff did not have a clear enough system for recording creams and ointments when they were applied. Medicine storage temperatures also needed effective monitoring, and controlled drugs checks were not frequent enough.
“A clearer system was needed to enable staff to accurately record the application of people's topical medication at the time these were administered.” from the report
- 01How are applications of creams and ointments recorded now, and when was the new recording system introduced?
- 02How often are controlled drugs stock checks carried out now?
- 03How are medicine storage temperatures monitored and what happens if they fall outside recommended limits?
- 04How will you check that the medicines improvements have been followed consistently by all staff?
- 05Have the planned dementia-friendly signage improvements and the residents and family activity pack been completed?
This was an unannounced inspection covering all five CQC questions, including care, accommodation, medicines, records, staffing and management. This explanation was written from the published report of 24 January 2019 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, December 2017
Credenhill Court Rest Home was rated Requires Improvement; inspectors found kind, responsive care but gaps in medicines, records, consent and oversight.
Inspectors visited on two days, spoke with people living in the home, a relative and staff, observed care, and checked care plans, medicines records, staff checks, incidents and quality audits. The home provided care for up to 31 older people, with 30 people living there at the time.
People were generally treated with kindness and respect. There were enough staff, people enjoyed varied food and activities, and staff responded to changing needs and complaints. The caring and responsive areas were rated Good.
However, inspectors found problems with recruitment checks, unclear risk assessments, medicines records, consent and best-interest decisions. Care records were sometimes inaccurate or out of date, and the home's checks had not found these problems. Safe, effective and well-led were rated Requires Improvement.
The home breached Regulation 11 about need for consent and Regulation 17 about good governance. The previous overall rating was Good in March 2017, although well-led already required improvement.
Kind relationships
People experienced caring and respectful relationships with staff. Staff adjusted their approach to individual communication needs and helped protect privacy and dignity.
“People continued to enjoy respectful. positive and caring relationships and interactions with staff.” from the report
Enough staff
People and a relative said staff were available and had time to help. Inspectors saw staff respond promptly to anxiety and requests for assistance.
“There were enough staff to meet people's physical and emotional needs.” from the report
Food and healthcare
People had choices of food and drinks and access to a range of health professionals. Staff supported people who needed help with eating and drinking.
“People enjoyed the choice and variety of food offered on a daily basis.” from the report
Activities and feedback
People took part in activities, outings and hobbies, including one-to-one time for those who preferred to stay in their rooms. Complaints and suggestions were listened to and acted on.
“People's changing health and wellbeing needs were responded to.” from the report
Recruitment checks
seriousA domestic worker started without a DBS check, despite the home's own policy. The check was completed later, but the process had not been followed.
“Safe recruitment processes had not always been followed.” from the report
Risk assessments
seriousSome risk assessments were unclear, contradictory or out of date. Staff were not always familiar with the instructions for people's risks.
“Risk assessments contained contrary and inaccurate information.” from the report
Medicines records
seriousThere were no running balances on medicines records, some handwritten entries were not signed, and time-specific medicines were not clearly marked. This meant inspectors could not complete a full stock check.
“Medicines had not been audited to make sure these were all accounted for and had been administered safely.” from the report
Inaccurate care records
seriousCare plans included incorrect diagnoses, missing information and references to sections that were blank. This could have led to inappropriate or unnecessary care.
“People's care records contained inaccurate and out-of-date information about their health and care needs.” from the report
Weak quality checks
needs fixingThe home's audits had not routinely found or fixed problems. Before the inspection, no medicines audit had taken place for eight months.
“The quality assurance systems were not yet effective in identifying shortfalls in the service.” from the report
- 01How do you now make sure every staff member has completed the required DBS and reference checks before starting work?
- 02How are medicines stock balances, signatures and medicines that must be given before food checked and audited?
- 03How often are risk assessments and care plans reviewed, and how do you check that staff understand the current instructions?
- 04How are consent decisions and best-interest decisions recorded for people who have or lack capacity?
- 05Has the planned deputy manager been appointed, and what regular audits now check the quality and safety of care?
This was an inspection covering all five key questions, but the report gives conflicting inspection dates in different sections. This explanation was written from the published report of 30 December 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 Credenhill Court Rest Home
5 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- January 2019Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- April 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- December 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 14 January 2011.
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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11 live-in carers within about an hour of Herefordshire, County of
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £960 to £1,410 a week. 10 can care for a couple. 8 years' experience on average.
“She was very caring, kind and patient to all his needs, she built up a wondetful rapport with him, she was dedicated and was there for him through good times as well as through the tough times”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.