CQC report explained · a residential care home
What the CQC found at The Crown
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, December 2023
The Crown was rated Requires Improvement; inspectors found caring staff and safe medicines practice, but concerns about safeguarding, privacy, records and leadership.
Inspectors made two unannounced visits, over an evening and a weekend, on 27 September and 1 October 2023. They spoke with both residents, a relative and seven staff, and checked care, risk, medicine, recruitment and management records.
The home was not always safe. Potential safeguarding concerns had not all been reported to the local authority or the CQC. Records needed updating, CCTV had been installed without consulting residents or gaining their consent, and staffing did not always allow spontaneous outings or baths.
There were positive findings. Staff managed risks such as seizures, gave medicines as prescribed, kept the home clean and treated people with kindness and patience. A new manager had started making changes, but many were too recent for inspectors to judge whether they would last.
The overall rating changed from Good at the last inspection to Requires Improvement. This was a focused inspection of Safe and Well-led only, so the other question ratings were not reassessed.
Kind and respectful staff
Staff were attentive, patient and compassionate. They supported people calmly when they became distressed.
“We observed them to be attentive, kind and compassionate.” from the report
Managing health risks
Staff followed risk plans, including for seizures and distress. They also supported daily oral care.
“We observed staff consistently following agreed risk management procedures with this person to keep them safe.” from the report
Medicines and cleanliness
People received medicines as prescribed, and medicine records had no unexplained gaps. The home was clean and staff used protective equipment during personal care.
“Medicine administration records had been completed with no unexplained gaps and the reason for PRN (as and when required) medicines, had been recorded.” from the report
New manager taking action
The new manager acted quickly during the inspection and showed a strong commitment to improving the home. The changes were not yet established enough for inspectors to assess fully.
“They acted immediately to address the inspection findings; however, under the existing governance systems we could not be assured this would have been addressed if we had not inspected.” from the report
Safeguarding reports
seriousRecords showed that not all potential abuse concerns had been reported to the local authority safeguarding team or the CQC. Inspectors said this could have placed people at risk.
“Records showed staff had not reported all instances of potential abuse to the Local Authority safeguarding team or the Care Quality Commission (CQC).” from the report
CCTV and consent
needs fixingCCTV had been installed in communal areas without consulting residents or gaining their consent. Inspectors said this did not properly protect privacy and choice.
“The provider had installed CCTV in communal areas of the service however, they had not consulted with people living at the service or gained their consent to being filmed.” from the report
Records and quality checks
needs fixingSome records were old or contained another person's name. Quality audits did not identify all the issues found by inspectors and focused too much on systems rather than people's quality of life.
“We found records that were in need of review, due to age or content. For example, some records contained the name of a different person.” from the report
Staffing and choice
needs fixingStaffing did not always allow people to go out without planning ahead or choose when to have a bath or shower. Improvements were made during the inspection, but the home was discussing funding for staffing levels.
“However, staffing levels did not always enable people to go out spontaneously for example, to access community facilities, or to choose when to have a bath or shower.” from the report
- 01What safeguarding concerns have been reported to the local authority and the CQC since this inspection, and how are staff trained to recognise and report them?
- 02Have residents now been consulted about the CCTV, and what consent or best-interest decisions are recorded?
- 03What changes have been made to ensure records are accurate, current and stored safely?
- 04How many staff are on duty at different times, and can residents now go out or choose when to bathe without having to plan far ahead?
- 05How do your quality checks now measure residents' experiences and quality of life, rather than only checking policies and paperwork?
This was a focused inspection of Safe and Well-led only; the other question ratings were carried forward from the last inspection when calculating the overall rating. This explanation was written from the published report of 2 December 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, January 2020
Rated Good overall; inspectors found safe, kind and responsive care, but the home was not always well-led.
This was an unannounced inspection on 4 December 2019. One inspector spoke with or observed all three people living at the home, spoke with staff and checked care, medicine, recruitment and management records.
People were safe, treated kindly and supported to make choices. Staff helped with medicines, food, healthcare, activities and communication. Opportunities for meaningful activities had improved since the previous inspection.
The overall rating was Good. Safe, Effective, Caring and Responsive were all rated Good. Well-led remained Requires Improvement because the provider did not have strong enough checks to identify and fix all problems.
People felt safe
People told inspectors they felt safe. Staff understood safeguarding and managed risks calmly, including when people became distressed.
“People told us they felt safe living at the service and our observations found they were comfortable in the presence of staff.” from the report
Kind and respectful care
Staff listened to people, responded patiently and protected their privacy and dignity. People were involved in decisions about their care and daily routines.
“People were treated with kindness and compassion. It was clear people felt at ease with the staff and felt comfortable chatting with them or approaching them for support.” from the report
Choice and independence
People were supported to make choices, prepare food, develop skills and take part in activities. The building also included features intended to support independent living.
“People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.” from the report
Improved activities
Since the previous inspection, people had more opportunities to go out, follow interests and take part in social and cultural activities.
“Improvements had been made to increase people's social opportunities and involvement since the last inspection.” from the report
Better medicines processes
Medicine records had improved. Inspectors found no unexplained gaps in the records they checked, and a new count sheet was being used to identify errors.
“MARs had been completed with no unexplained gaps and the reason for PRN (as required) medicines, had been recorded.” from the report
Weak provider oversight
needs fixingThe provider had not shown that it regularly checked the quality and safety of the home. This meant some problems were not identified or addressed through the provider's own monitoring.
“There was still no evidence of provider level monitoring and oversight, and we identified areas that still required improvement.” from the report
Training gaps
needs fixingInspectors found gaps in training needed for people's assessed needs, including autism. Further training had been sourced, but it was not yet complete.
“However, we found gaps in the training provided to meet people's assessed needs, such as autism.” from the report
Unclear financial contributions
needs fixingThere were no clear written records showing agreement or best-interest decisions about people paying staff costs on outings. There was also no clear breakdown of what people or the home should pay.
“There was no evidence of this happening however, there were no written records to show this had been agreed to by the people involved or assessed as being in their best interests” from the report
Agency recruitment records
needs fixingRecords for agency staff did not initially show that all legally required checks had been completed. The agency confirmed the checks were in place before the inspection ended.
“Records were also in place for agency staff, but these did not evidence that all legally required checks had been carried out.” from the report
- 01What provider-level quality checks are now carried out, and how are actions recorded and followed up?
- 02Has all staff training for autism and other assessed needs now been completed?
- 03What recruitment checks are recorded before agency staff start work at the home?
- 04What is the written policy on people paying staff costs during outings, and how are consent and best-interest decisions recorded?
- 05Have the more personalised support plans and monthly keyworker sessions now been introduced?
This was an unannounced planned inspection covering all five CQC questions, following the home's previous Requires Improvement rating. This explanation was written from the published report of 10 January 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.
Every inspection of The Crown
3 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- December 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2020Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- December 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2017
Registered with the Care Quality Commission on 7 September 2017.
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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