CQC report explained · a residential care home
What the CQC found at Crossbrook Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- People's risks were assessed and reviewed, staff numbers had improved, and medicines were managed safely. Some people initially said they did not feel safe because of the compatibility of people they lived with, although they later said they felt safe.
- Effective?
- Good
- Staff training, supervision and support had improved. People's health needs were supported with greater involvement from external professionals, although records of best-interest decisions still needed improvement.
- Caring?
- Good
- People and relatives described permanent staff as kind and caring. People were involved in care reviews and supported to follow their religious beliefs and cultural preferences.
- Responsive?
- Requires improvement
- Care was not yet consistently personalised. Records needed more detail, staff were still learning people's preferences, and there were not enough activities for people when they were not going out.
- Well-led?
- Requires improvement
- The provider had introduced more audits, checks and management support, but leadership and communication were not yet consistent. Care records and the culture of personalised support still needed further improvement.
What inspectors found, May 2023
Overall Requires Improvement; inspectors found safe, kind care, but personalised support and leadership were not yet consistent.
This was an unannounced follow-up inspection by three inspectors. They spoke with people, relatives, staff and health and social care professionals. They observed care and reviewed five people's care records, medicines records and other management records.
The home was rated Good for Safe, Effective and Caring. Inspectors found safer staffing, improved medicines management, better staff training and more involvement for people and relatives. Restrictions on people's freedom were reviewed and reduced where possible.
The home was rated Requires Improvement for Responsive and Well-led. Care records did not always contain enough personalised information, staff were still learning people's preferences, and there were not enough activities inside the home. Leadership and communication also needed to become more stable and consistent.
The overall rating improved from Inadequate at the previous inspection. The home was no longer in breach of regulations and was removed from Special Measures, but inspectors said the improvements needed to become established and last.
Permanent staffing
The provider had recruited a permanent staff team. Inspectors said this improved continuity for people and relatives.
“At this inspection we found the provider made significant improvements and they had recruited a full permanent staff group.” from the report
Medicines safety
Staff were trained and assessed before giving medicines. Inspectors found that medicines counted for three people matched the records.
“We found staff were trained, and their competency had been assessed before they administered people's medicines.” from the report
Kind and respectful care
People and relatives gave positive feedback about permanent staff. People were supported with their religious beliefs and cultural requirements.
“People and relatives told us permanent staff were kind and caring.” from the report
Better partnership working
The provider involved external health and social care professionals more regularly in reviews and care planning.
“The provider worked on establishing good links with commissioners, social workers involved in people's care and learning disability specialists.” from the report
More community activities
People had more opportunities to go out, including shopping, cinemas, the seaside and other activities they chose.
“There was a significant improvement in people going out and about in the community, going shopping, to cinemas, visiting the seaside or other activities they chose to do.” from the report
Personalised care records
needs fixingCare records did not yet include all the information staff needed to provide consistently person-centred support. Staff were still learning people's likes, dislikes and preferences.
“Care records needed improving further to ensure all the information staff needed to support people in a person-centred way, had been captured.” from the report
Activities inside the home
needs fixingPeople were supported to go out more, but there were not enough engagement opportunities when they stayed in the home. One person's television was not working, limiting their choices.
“We found that people were engaged in outdoor activities, however further improvements were needed to ensure people had enough engagement opportunities when they were not going out.” from the report
Management stability
needs fixingThe home had an interim manager and no registered manager had been in place since 06 May 2022. Inspectors also found that communication was not always as good as it should have been.
“However, the provider had no registered manager in place since 06 May 2022.” from the report
Admission assessments
needs fixingFor emergency admissions, assessments were sometimes completed after people arrived. The provider said it had reviewed its admission process.
“However, in case of an emergency admission the assessment had been completed after people arrived in the service.” from the report
Records of decisions
needs fixingInformation about best-interest decisions was sometimes kept in emails or other correspondence rather than in care records. This could make it harder to understand how decisions were made.
“This communication was not always in the care records but held electronically in emails or other correspondence.” from the report
- 01How will you make sure my relative's care plan records their likes, dislikes, communication needs and personal goals in enough detail?
- 02What activities are available inside the home when residents are not going out, and how do you make sure these reflect each person's interests?
- 03Who is currently responsible for managing the home, and when will a registered manager be in place?
- 04How do you record best-interest decisions and make sure all relevant discussions are included in the care records?
- 05How do you assess whether a person is suitable for the home before an emergency admission?
This was an unannounced follow-up inspection covering all five key questions and infection prevention and control, after the previous Inadequate inspection. This explanation was written from the published report of 26 May 2023 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, September 2022
Crossbrook Court was rated Inadequate and placed in special measures; inspectors found serious shortfalls in personalised care, staffing, risk management and leadership.
This was an unannounced inspection carried out on 1 June, 5 June and 4 July 2022. Inspectors spoke with people, relatives and staff, observed care, and checked care records, medicines, staff records and management systems.
The home supported 12 people with learning disabilities and autistic people. Inspectors found that people did not consistently have enough choice, independence or meaningful activities. Some doors, toilets and a kitchen were locked without enough consideration of less restrictive options. Care plans and risk assessments were not always accurate or detailed enough, and agency staffing meant some staff did not know people's needs or communication methods.
The overall rating fell from Good to Inadequate. Safe, Effective and Caring were rated Requires Improvement. Responsive and Well-led were rated Inadequate. The home was placed in special measures, and the provider was given warning notices requiring improvements within three months.
Fire and premises checks
Health and safety and fire safety checks had been reviewed. Each person had a recently reviewed emergency evacuation plan.
“Maintenance records showed checks were completed by external professionals.” from the report
Infection control
Inspectors found effective infection control arrangements, including cleaning, protective equipment, testing and visiting arrangements.
“The service used effective infection, prevention and control measures to keep people safe, and staff supported people to follow them.” from the report
Recruitment checks
The recruitment process included checks on work history, references and criminal records.
“Pre-employment checks were in place and included staff's work history, references and making checks for any criminal records.” from the report
Some health support
People had health passports for appointments and some people were supported with health checks, weight loss and hospital care.
“People had health passports which were used by health and social care professionals during appointments.” from the report
Restrictions on freedom
seriousSome toilets and a kitchen were locked, without individual assessments showing that these were necessary or the least restrictive options.
“The provider had failed to properly assess a person's mental capacity for a specific decision and failure to ensure only the least restrictive methods were used to uphold people's rights under the MCA.” from the report
Limited personalised activities
seriousPeople were not consistently supported to pursue interests, employment, social activities or goals. Inspectors found little structured support to build skills and independence.
“People did not receive quality, structured, personalised care that gave them choice and control and supported aspirations and social inclusion.” from the report
Communication support
needs fixingStaff did not have the skills to use people's preferred communication methods, including Makaton, pictures and symbols. Care information was not consistently available in the formats people needed.
“However, staff were not observed to be using these communication tools and told us they did not have the training to offer choices tailored to individual people using a communication method appropriate to that person.” from the report
Weak management checks
seriousAudits and staff observations did not identify important problems in care, records, restrictions or staff practice. Feedback from people and relatives was not reliably acted on.
“Systems were either not in place or robust enough to demonstrate the service was effectively managed.” from the report
Medicines privacy
minorMedicines were sometimes explained and given in communal areas, which did not consistently protect people's privacy and dignity.
“This could sometimes mean medicines being explained and administered in communal spaces in front of other people living at the service and visitors.” from the report
- 01What specific changes have been made to the risk assessments and care plans for someone with diabetes, epilepsy or changing mental health needs?
- 02How many permanent staff are now working at the home, and how do you check that agency staff understand each person's communication and sensory needs?
- 03Which toilets, kitchens or other areas are locked now, and how has the home shown that any restrictions are necessary and the least restrictive option?
- 04What individual plans are in place to support my relative's interests, community activities, employment wishes and development of independence?
- 05How are people and relatives now involved in reviewing care, raising concerns and checking that agreed actions have happened?
This was an unannounced inspection covering all five key questions, including infection prevention and control; the previous Good ratings were reassessed and all five ratings deteriorated. This explanation was written from the published report of 6 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.
Every inspection of Crossbrook Court
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- May 2023Requires improvementcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2022Inadequatedown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- July 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015
Registered with the Care Quality Commission on 16 March 2015.
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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