CQC report explained · a residential care home
What the CQC found at Crouched Friars Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found safeguarding systems, risk assessments, fire procedures and infection controls were generally effective. They noted increased whistleblowing concerns before the inspection, some undated creams and limited information on handover sheets.
- Effective?
- Good
- People received support from health professionals and had appropriate care plans, training and help with eating and drinking. Inspectors noted that staff training completion had been difficult to maintain and that more awareness of sexual safety for people with dementia would help.
- Caring?
- Good
- Caring was not covered by this focused inspection, so the report does not give a new rating for this question.
- Responsive?
- Good
- Care plans were regularly updated and reflected people's preferences, communication needs and end-of-life wishes. Complaints were investigated, and the home supported religious services, family contact and individual activities.
- Well-led?
- Good
- The managers had introduced audits and acted on issues identified. Inspectors found that the previous governance breach had been addressed, although environmental improvement work was still continuing.
What inspectors found, October 2022
Rated Good after improvements; inspectors found safe, kind and person-centred care, with some staffing and premises issues still being managed.
This was an unannounced focused inspection. Inspectors visited the home, reviewed six care plans and risk assessments, observed care and a mealtime, and spoke with people, relatives, staff and health professionals. They also checked audits, infection control and other management records.
The home was rated Good overall. Safe, Effective, Responsive and Well-led were rated Good. People were generally protected from harm, supported with health needs, offered choice and personalised care, and able to raise concerns. Relatives said people were safe and that visiting was flexible.
The home had improved since the previous inspection, which was rated Requires Improvement and found a breach of Regulation 17. At this inspection, the provider had made enough improvement and was no longer in breach. Caring was not inspected during this focused visit, so no new rating was given for it.
Safeguarding
The manager investigated concerns and made appropriate safeguarding referrals. Staff knew how to report concerns, and relatives said they felt able to raise issues.
“The registered manager made appropriate referrals to safeguarding bodies, for example in the event of unidentified bruising.” from the report
Personalised care
Care plans recorded people's preferences and how staff should support them. Staff encouraged choice and independence, including for people living with dementia.
“People's care plans clearly identified their preferences and how they wished to be cared for. People's independence was encouraged.” from the report
Food and nutrition
People had a choice of meals, drinks and snacks. Staff monitored people's food, fluid intake and weight, and sought professional advice when needed.
“People had access to and choice of different hot and cold drinks and snacks throughout the day.” from the report
Improved management
The home had acted on the previous inspection findings. Audits, meetings and checks were being used to identify and address problems.
“The registered and deputy manager had worked hard to make the necessary improvements following the last inspection.” from the report
Staffing was not always consistent
needs fixingAlthough inspectors saw people get help when needed and most feedback was positive, some staff said there were not always enough staff on duty. The home was using agency staff and recruiting.
“Two staff told us there were not always enough staff on duty, although three members of staff told us there were enough.” from the report
Medicine creams were not dated
minorInspectors found two opened creams in the fridge without opening dates. The manager was working with staff to improve this.
“We found two creams kept in the fridge had been opened but not dated.” from the report
Clinical room flooring needed replacement
minorThe flooring had holes and did not support good infection control. Replacement plans were in place.
“The clinical room lino flooring did not allow for good infection control and had holes in various areas.” from the report
- 01How many staff are normally on duty during the day and at night, and how do you respond when staffing is short?
- 02What has been done to make sure opened medicine creams are dated and checked?
- 03Has the clinical room flooring been replaced, and what is the timetable for completing this work?
- 04How do staff receive complete handover information about people's needs when electronic records are not immediately available?
- 05What work is continuing in Colne Lodge, and how are people living with dementia affected while improvements are being made?
This was a focused inspection covering Safe, Effective, Responsive and Well-led; Caring was not inspected and the report says the other ratings were used from the previous inspection where applicable. This explanation was written from the published report of 8 October 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, June 2021
Crouched Friars Residential Home was rated Requires Improvement; inspectors found kind care but staffing, call bell response and management systems were not reliable enough.
This was an unannounced focused inspection on 19 May 2021. Two inspectors and an Expert by Experience spoke with people, relatives and staff, and checked care, medicines, recruitment and management records.
People said staff were kind and caring and that they felt safe. However, people and staff said more staff were needed. Inspectors saw people waiting after using their call bells, and the manager could not monitor response times. Some records lacked detail, and audits did not always identify patterns or lead to improvements.
The overall rating remained Requires Improvement, as did Safe and Well-led. The other three areas were not inspected during this visit, so their previous ratings were used. The provider breached Regulation 17 on good governance and was asked to produce an action plan.
Kind and caring staff
People said they felt safe and described staff as kind and caring.
“Everyone described the staff as being kind and caring.” from the report
Recruitment checks
Inspectors found that the required checks had been completed for new staff.
“Recruitment checks had been carried out on new staff which met requirements.” from the report
Medicines processes
Medicines records were complete, staff had training and their competence was checked. Historic medicine errors had been dealt with appropriately.
“Medication Administration Records (MARs) were fully completed and had no gaps.” from the report
Infection prevention
Inspectors were assured that the home had arrangements for infection prevention, personal protective equipment, testing and visits in line with current guidance.
“We were assured that the provider was using PPE effectively and safely.” from the report
Staffing and call bells
seriousPeople and staff said there were not enough staff, and inspectors saw people waiting for help after pressing call bells. The manager could not monitor how quickly calls were answered.
“There is not enough staff. There is no telling how long you might wait when you press your alarm.” from the report
Building safety
needs fixingInspectors found an easily accessible stairway between buildings and uneven floors. They said the home might not be suitable for some people.
“There was a stairway connecting two buildings that people could easily access, and a number of uneven floors throughout the home.” from the report
Weak quality checks
seriousAudits did not always identify problems or lead to changes. Falls data was not analysed for themes and trends, and staffing problems had not been identified.
“the information had not been analysed, to look for themes and trends, so changes had not been implemented to make the service safer.” from the report
Incomplete care records
needs fixingSome daily records did not contain enough detail, and one person's repositioning chart had gaps.
“the recording in some people's daily record needed greater detail, and there some gaps in one person's turn chart.” from the report
- 01How many staff are on duty on each shift now, and how are they deployed across the three connected buildings?
- 02How quickly are call bells answered now, and what system is used to monitor response times?
- 03What has been done about the accessible stairway and uneven floors?
- 04How are falls now reviewed for patterns, and what changes have been made as a result?
- 05How are daily care records and repositioning charts checked to make sure they are complete?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were used. This explanation was written from the published report of 24 June 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 Crouched Friars Residential Home
9 rated inspections over 7 years: the service has held its Good rating throughout.
- October 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Crouched Friars Residential Home →
- June 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Crouched Friars Residential Home →
- March 2020Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2019Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- February 2019Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2018Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- February 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2016Goodstayed GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- May 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- October 2011
Registered with the Care Quality Commission on 5 October 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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