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CQC report explained · a nursing home

What the CQC found at Creedy House

Requires improvementpublished 12 March 2025, 18 months ago

Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.

The latest report, explained

What inspectors found, December 2020

Inspected but not rated; inspectors were assured that infection prevention and control procedures were safe.

This was an unannounced, targeted inspection on 26 November 2020. It checked infection prevention and control because the home was responding to coronavirus outbreaks.

Inspectors found good practice for visitors, including health screening and protective equipment. People isolating in their rooms were kept occupied, and staff supported people living with dementia to use separate communal areas safely.

The home was inspected but not rated. The inspection only looked at infection prevention and control, so it does not give an overall judgement on the quality of care.

What inspectors praised
  • Visitor safety

    Visitors were screened for recent contacts and had their temperature taken. They were also given protective equipment.

    “Visitors to the service were asked to complete a questionnaire about recent contacts, their temperature taken, and they were provided with Personal Protective Equipment (PPE).” from the report
  • Support for people with dementia

    The home used separate communal areas to help people who liked to walk around remain safe and keep their distance from others.

    “Staff encouraged them to use specific separate communal areas, to keep them safe and maintain social distance.” from the report
  • Support during isolation

    People isolating in their rooms were given activities and personal contact to help keep them occupied.

    “Staff said they would sing and chat with people to keep their spirits up.” from the report
  • Infection controls

    Inspectors were assured that the home had arrangements covering protective equipment, testing, hygiene, admissions and outbreak management.

    “We were assured the service were following safe infection prevention and control procedures to keep people safe” from the report
What inspectors were concerned about

Inspectors raised no specific concerns in this report.

Questions to ask them, based on this report
  1. 01How do you currently screen visitors and provide protective equipment?
  2. 02How do you support people who need to isolate in their rooms?
  3. 03How do you support residents living with dementia who like to walk around while maintaining their safety and social distance?
  4. 04How do you access coronavirus testing for residents and staff?
  5. 05What is your current plan for preventing and managing an infection outbreak?

This was a targeted inspection of infection prevention and control only; the service was inspected but not rated and the other areas were not assessed in detail. This explanation was written from the published report of 19 December 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.

An earlier report, explained

What inspectors found, December 2019

Rated Good; inspectors found safe, kind and personalised care, with improvements since the previous Requires Improvement rating.

This was an unannounced inspection over two days. Inspectors spoke with people living in the home, relatives and staff. They also observed care and reviewed care plans, medicines records, recruitment files and management records.

The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines systems, suitable staff training and good support with health, food, activities and communication.

The home had improved since the previous inspection, which was rated Requires Improvement and found three breaches of regulation. At this inspection, the provider had made enough progress and was no longer in breach of those regulations.

What inspectors praised
  • Enough staff

    The home had enough staff to meet people's needs. Agency staff were used when needed, with efforts made to provide consistency.

    “There were sufficient staff to meet people's needs. The registered manager calculated the number of staff required according to people's needs.” from the report
  • Safe medicines

    Medicines were ordered, stored and given safely. Staff followed instructions for medicines given when needed, including for anxiety or agitation.

    “Medicines were managed safely. There were clear systems in place for the ordering, storage and administration of medicines.” from the report
  • Kind and respectful care

    People were treated with patience, kindness and dignity. Staff adapted how they approached people and supported them to do things for themselves.

    “We observed people being treated with patience and kindness. Staff knew how to approach people and adjusted their manner accordingly.” from the report
  • Personalised care

    Care plans included people's routines, preferences and possible causes of distress. Staff knew how to support people in line with this information.

    “Care plans contained detailed information about people's choices and preferences.” from the report
  • Activities and relationships

    People could take part in arts and crafts, exercises, singing, dancing and pet therapy. People staying in their rooms received individual visits.

    “There were now arts and crafts sessions, people's pictures had been displayed in the lounge.” from the report
What inspectors were concerned about
  • Recording relatives' involvement

    minor

    Relatives had helped develop and review care plans, but the electronic system could not record this at the time. The manager agreed to investigate whether the system could be updated.

    “The registered manager told us there was not a way at present to record this on the electronic care plan system.” from the report
Questions to ask them, based on this report
  1. 01How do you now record relatives' involvement in developing and reviewing care plans?
  2. 02How do you check that staff recruitment records remain complete, including full employment histories?
  3. 03How are people's recommended fluid amounts monitored, and what action is taken if they do not drink enough?
  4. 04How do you check that care plans continue to reflect people's routines, choices and preferences?
  5. 05What activities are currently available for people who stay in their rooms or have dementia?

This was an unannounced, planned inspection based on the previous rating and covered all five CQC questions. This explanation was written from the published report of 14 December 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.

The story over the years

Every inspection of Creedy House

6 rated inspections over 5 years: the service has held its Good rating throughout.

  1. December 2020Inspected but not ratedcurrent rating
    Safe: Inspected but not rated

    Read what inspectors found at Creedy House →

  2. December 2019Goodup from Requires improvement
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read what inspectors found at Creedy House →

  3. December 2018Requires improvementstayed Requires improvement
    Safe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement

    Read this report on cqc.org.uk

  4. May 2018Requires improvementstayed Requires improvement
    Safe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate

    Read this report on cqc.org.uk

  5. March 2017Requires improvementup from Inadequate
    Safe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement

    Read this report on cqc.org.uk

  6. September 2016Inadequatedown from Good
    Safe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate

    Read this report on cqc.org.uk

  7. January 2015Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read this report on cqc.org.uk

  8. January 2014

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  9. August 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  10. February 2011

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  11. November 2010

    Registered with the Care Quality Commission on 4 November 2010.

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.

Next steps

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