CQC report explained · a residential care home
What the CQC found at Crimson Manor
Rated Inadequate: inspectors found the home performing badly and the CQC has taken enforcement action.
What inspectors found, July 2022
Rated Good overall; inspectors found safe, kind and responsive care, but the home still needs to improve its management systems.
This was an unannounced follow-up inspection on 28 April and 6 May 2022. Inspectors spoke with six people, five relatives and several staff. They reviewed care records, medicines, recruitment files and management records.
People were found to be safe. Risks were assessed and reviewed, medicines were administered safely, staffing levels were suitable and staff understood safeguarding. Infection control arrangements were generally suitable, although inspectors found an overflowing clinical waste bin and two toothbrushes stored inappropriately. These issues were dealt with after, or during, the inspection.
People received good support with food, healthcare, communication, activities and daily choices. Inspectors saw kind and respectful interactions. Care plans contained enough information about people's needs and preferences.
The overall rating was Good. Safe, Effective, Caring and Responsive were all rated Good. Well-led remained Requires Improvement because weights were not recorded consistently, some audits lacked detail and one incident was not reported to CQC without delay.
Safe care
Risks were assessed and reviewed. Staff had safeguarding training and understood how to recognise and report possible abuse.
“People told us they felt safe living at this home and their relatives agreed.” from the report
Kind staff
Inspectors saw staff communicating well and treating people with dignity. People and relatives were positive about the staff team.
“We witnessed positive interactions between people and staff throughout the day of inspection.” from the report
Good activities
People were offered varied activities, including exercise, quizzes, singing and a dementia-focused programme. Inspectors saw people joining in and enjoying themselves.
“We observed people were getting involved and enjoying themselves. People were laughing and appearing to have fun.” from the report
Improvement since 2019
The provider had addressed the earlier problems with risk management, consent and care planning. The home was no longer in breach of regulations at this inspection.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulations.” from the report
Weight records
needs fixingPeople's weights were recorded in different paper and electronic systems and were not always recorded. This included one person who needed weekly monitoring, although inspectors found no impact on that person.
“The recording of people's weights was not organised. Some records were on paper and others were electronic.” from the report
Audits lacked consistency
needs fixingSome audits did not contain enough detail. The nutrition audit did not clearly identify which people needed more attention, and medicine temperature records were not up to date.
“However, further improvements were needed regarding recording of people's weights and ensuring systems of audit were consistently robust.” from the report
Late incident notification
needs fixingAn incident from December 2021 was not separately reported to CQC without delay. The provider reported it separately after the inspection.
“This information was incorporated into another notification for the same person we received two weeks later, which meant this was not reported without delay.” from the report
- 01How are you now recording and checking each person's weight, especially where weekly monitoring is needed?
- 02What checks ensure medicine room and fridge temperatures are recorded every day?
- 03How do you make sure incidents are reported to CQC without delay?
- 04Which people are identified as needing extra support with nutrition, and how is this followed up?
- 05How will the planned extra activities coordinator affect the activities available across the week?
This was an unannounced follow-up inspection after the 2019 rating and action plan, and it reviewed all five key questions as well as infection prevention and control. This explanation was written from the published report of 21 July 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 2019
Crimson Manor was rated Requires Improvement; inspectors found safety risks, incomplete records and weak management oversight.
Inspectors visited on 13, 20 and 23 May 2019. The first visit could not go ahead because of an infectious outbreak. They spoke with people, relatives and staff, observed care, and checked care, medicine, training and management records.
The home was rated Requires Improvement in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found the call buzzer and sensor mats had not worked for several weeks. They also found concerns about bruising records, falls and skin risks, infection control, maintenance, medicines records and people's bathing arrangements.
Care plans and daily records did not always show that people's needs, choices and care instructions were being followed. Mental capacity and best-interest records were incomplete. Audits and management checks had not identified or fixed some repeated problems.
There were positive findings too. People spoke well about activities, meals and many staff interactions. However, the home had deteriorated from its previous Good rating in 2016, and the provider was told to make improvements.
Activities
The home offered regular activities, including group and one-to-one sessions. People and relatives gave positive feedback about these activities.
“There was a regular and varied programme of activities happening at the home.” from the report
Meals
People spoke positively about the food. Inspectors saw a relaxed and sociable mealtime.
“People shared positive feedback about the meals and our observations confirmed the meal time experience for people was relaxed and sociable.” from the report
Staff interactions
Inspectors saw relaxed interactions, with people appearing comfortable around staff. Staff engaged with people appropriately.
“Interactions between staff and people living at the service were relaxed, people seemed comfortable in the presence of staff and staff were proactive in engaging with people in an appropriate way.” from the report
Medicine administration
People generally received their medicines when they should, and medicines were given in a person-centred way. The main problem was with some recording.
“People's medicines were administered in a person-centred way and people were receiving their medicines when they should.” from the report
Call system and falls risk
seriousThe call buzzer and sensor mats had not worked for four weeks. Extra checks were introduced, but records did not always prove they happened and inspectors were not assured that risks had been managed promptly.
“The home's call buzzer system and sensor alarm mats had been inoperative for the last four weeks before our inspection” from the report
Bruising and safeguarding records
seriousBruises found on two people were not accurately recorded or fully investigated. Inspectors referred their concerns to the local safeguarding team.
“We found the provider's approach to reviewing and investigating the causes of these incidents was insufficient.” from the report
Care records
needs fixingCare plans varied in quality and did not always contain enough detail about important support. Daily records also had gaps and did not always show that planned care was delivered.
“The quality of care plans was variable; some areas of people's care plans were individuated, other areas lacked detail in relation to important areas of their care.” from the report
Bathing and privacy
seriousRecords did not always show that people's bathing preferences were followed. One person had not been offered a bath or shower during a two-week period.
“Records indicated that another person had not being offered a bath or shower in the period of two weeks.” from the report
Management checks
seriousAudits had not reliably found or fixed problems. Some issues appeared in repeated audits and were still present during the inspection.
“Quality management systems were not effective.” from the report
- 01Is the call buzzer and sensor mat system now working reliably, and how are checks recorded when equipment fails?
- 02How are bruises, falls and other incidents now recorded, investigated and reviewed for learning?
- 03How do you check that care plans contain enough detail and that daily records show planned care has been delivered?
- 04How are mental capacity assessments and best-interest decisions completed and checked for every relevant decision?
- 05What changes have been made to management audits so repeated problems, including infection control and medicines records, are fixed promptly?
This was an unannounced comprehensive inspection covering all five key questions, including the premises and care provided; the previous ratings were from 2016. This explanation was written from the published report of 15 October 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.
Every inspection of Crimson Manor
5 rated inspections over 7 years: the service has improved, from Inadequate to Good.
- July 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2016Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2015Inspected but not ratedSafe: Inspected but not rated
- March 2015InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- August 2013
Registered with the Care Quality Commission on 30 August 2013.
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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