CQC report explained · a residential care home
What the CQC found at Crelake House Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- People were protected from abuse, there were enough staff, and medicines were usually given as prescribed. However, risk assessments did not always cover risks linked to medicines, and some recruitment records were not readily available.
- Effective?
- Good
- This area was not inspected during this focused visit. The report says the previous rating was used when calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this focused visit. The report says the previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This area was not inspected during this focused visit. The report says the previous rating was used when calculating the overall rating.
- Well-led?
- Good
- The home had clear leadership, regular staff meetings and established systems for monitoring quality. The manager was described as open to feedback and focused on improvement.
What inspectors found, September 2022
Crelake House Residential Care Home was rated Good overall, but Safe Requires Improvement because some medicine risks were not fully assessed.
This was an unannounced, focused inspection on 8 and 17 August 2022. Inspectors spoke with people living at the home, relatives and staff. They reviewed care and medicine records, recruitment files, and quality checks.
The home had enough staff and people were generally protected from abuse and avoidable harm. Medicines were given as prescribed, but some medicine-related risks were not recorded fully. One medicine had not been dated when opened, so its expiry date could not be confirmed. It was no longer needed and was disposed of during the inspection.
The overall rating was Good. Safe was rated Requires Improvement and Well-led was rated Good. Safe had fallen from Good at the previous inspection, while Well-led had improved from Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were used in the overall rating.
Enough staff
People and relatives said there were enough staff. Inspectors saw staff respond quickly, and staff knew people's needs well.
“There were sufficient numbers of staff available to meet people's needs.” from the report
Safeguarding
Staff understood safeguarding responsibilities and knew how to report concerns. Safeguarding alerts were reported to the local authority and managed appropriately.
“People were protected from the risk of abuse and avoidable harm as staff were aware of their safeguarding responsibilities and knew how to report any concerns.” from the report
Person-centred care
Staff knew people's routines, preferences and needs. Records showed that care and support were tailored to individuals.
“Care records we looked at demonstrated people received person-centred care and support.” from the report
Improved leadership
Quality checks and reporting systems were embedded into the home's routines. The manager supported staff and welcomed feedback from the inspection.
“At this inspection we found the systems to monitor the quality of the service provided to people and reporting practices were in place and embedded into routines.” from the report
Medicine risk assessments
seriousSome risk assessments did not include the extra risks from medicines such as anticoagulants or self-administration. Inspectors recommended that medicine information in risk assessments and care plans be updated.
“Risk assessments did not always consider the additional risk posed by some of the medicines people were taking.” from the report
Medicine storage records
needs fixingOne medicine had not been dated when opened, so its expiry date could not be confirmed. It was no longer needed and was disposed of during the inspection.
“However, one medicine could not be confirmed as being within its expiry date as it had not been dated when opened.” from the report
Recruitment records
needs fixingSome information collected during staff recruitment was not readily available. The manager took immediate action after inspectors raised this.
“However, other information collected about candidates during the recruitment process were not always readily available.” from the report
Masks in communal areas
minorInspectors noted that staff were not wearing masks in communal areas. The manager explained how related risks were managed, but inspectors recommended seeking infection-control advice.
“We recommend the provider seeks advice from the local authority's infection prevention and control team or Public Health England around mask wearing for care staff in communal areas.” from the report
- 01How have you updated risk assessments for people taking anticoagulants or managing their own medicines?
- 02What person-centred information is now recorded about alternatives to 'when required' medicines for people who may become agitated?
- 03What recruitment information was missing or difficult to find, and how do you now make sure these records are kept properly?
- 04What advice have you received about staff wearing masks in communal areas, and what is the home's current approach?
This was an unannounced focused inspection of Safe and Well-led only; the other three key question ratings were carried over from the previous inspection. This explanation was written from the published report of 24 September 2022 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, October 2021
Crelake House Residential Care Home was inspected but not rated; inspectors found infection controls in place after a previous breach.
This was an unannounced, targeted inspection on 29 September 2021. One inspector looked only at infection prevention and control, following an earlier warning notice. They spoke with five people, three staff and reviewed related records.
Inspectors found that the home had systems to reduce the risk of infection. Staff used and disposed of PPE safely. The home was clean and free from unpleasant smells. Testing, training, visits and infection-control checks were in place.
The home was previously rated Good in February 2019. This inspection did not give a new rating and did not assess the whole service. Inspectors said the earlier infection-control breach had been fixed, so the provider was no longer in breach of Regulation 12.
PPE and hygiene
Staff wore PPE appropriately, disposed of it safely and were supported to put it on and take it off safely. Inspectors found the home clean and free from unpleasant smells.
“We found staff wore masks throughout our visits and the home was clean and odour free.” from the report
Testing arrangements
People, staff, visitors and professionals were tested in line with the arrangements described in the report.
“People were tested for Covid 19 to ensure they were negative prior to coming to live at the service” from the report
Safe visiting
People told inspectors they were happy with the infection-control measures and could have regular visits that were completed safely.
“They could have regular visits and the staff made sure these were completed safely.” from the report
Improvement after warning
The provider had made enough improvement to meet the requirements linked to the earlier infection-control warning notice.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 12.” from the report
Previous infection-control breach
seriousAt the earlier inspection, inspectors found inadequate infection-control measures and issued a warning notice. This inspection found that the breach had been resolved.
“At our last inspection the provider had failed to ensure they had adequate infection prevention control measures in place.” from the report
- 01What infection-control checks are currently carried out, and how do you know staff follow the required procedures?
- 02What arrangements are now used for PPE, testing and visits?
- 03What changes were made after the previous Regulation 12 breach and Warning Notice?
- 04When was the last full inspection, and what were the findings for care, staffing, medicines and management?
This was a targeted inspection of infection prevention and control under Safe only; it did not assess the other key questions or the whole Safe question, and the previous overall rating remained Good. This explanation was written from the published report of 12 October 2021 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 Crelake House Residential Care Home
5 rated inspections over 6 years: the service has held its Good rating throughout.
- September 2022Goodcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Crelake House Residential Care Home →
- October 2021Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Crelake House Residential Care Home →
- February 2021Inspected but not ratedSafe: Inspected but not rated
- February 2019Goodup from InadequateSafe: GoodWell-led: Requires improvement
- October 2018Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2017Goodstayed GoodSafe: Requires improvementWell-led: Requires improvement
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
- August 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- January 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 6 December 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.
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