Culrose Residential Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this meant we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question inadequate. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

The service had been in breach of legal regulation in relation to people’s safe care and treatment, premises and equipment, staffing, safeguarding service users from abuse and improper treatment. At this assessment we found the service was no longer in breach of these regulations.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. The registered manager listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The registered manager had developed a significant event analysis form, which was completed for incidents, accidents and significant events, such as equipment failure as well as for positive events, such as Victory Europe (VE) day celebrations, to capture what did and did not go well and identify lessons learnt. These were then reviewed, actions implemented and shared with the staff team. Staff told us they were encouraged to put forward ideas for improving training, meeting people’s needs or raising concerns and they received constructive feedback which ensured their input made a positive difference.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There was evidence of good working relationships with healthcare professionals. There were weekly visits to the service by the nurse practitioner from the local GP surgery and multi-disciplinary team meetings were held with the GP to review people’s individual care when needed. Although people did not often move on to another care setting when this had happened the registered manager received a compliment due to the amount of information shared to help with the transition such as life history, likes, dislikes and also ensuring there was sufficient medication.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that, however, did not always report this to the appropriate bodies. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The registered manager had shared appropriate events with the local safeguarding team, however, we identified these had not all been reported to CQC, which was a regulatory requirement. The registered manager was responsive in ensuring these notifications were submitted retrospectively. Staff had received training in safeguarding and those spoken to understood different types of abuse and knew how to report if they were concerned about a person.

The provider did not always work well with people to identify, understand and manage risks. Records did not always demonstrate staff provided care to meet people’s needs.

We identified not all risks were identified and mitigated for such things as diabetes, pre-diabetes and weight management. Records did not always demonstrate people had enough fluids to meet their hydration needs. Weight management was tailored around ensuring people kept or put on weight. But the risks of being obese had not been identified or mitigation put in place. This put people at risk of not receiving care needed to keep them healthy. However, there was no impact identified, and it was identified this was a recording issue and people were receiving appropriate care.

We identified restrictions to people in relation to visiting of relatives, searching relative’s belongings and physical restraint, which had not been probably risk assessed, or identified as the least restrictive option. With regards to visiting appropriate liaison had taken place with health care professionals, however, this had not been appropriately documented. The registered manager told us physical restraint had not been used and reference to it needed removing from the records. This put people at risk of restrictions being placed on them which were not required.

The registered manager responded promptly to the concerns raised to ensure systems were put in place to improve monitoring and escalation of concerns.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. However, we identified a recommendation from the legionella water testing from 2024 which had not been taken forward. The registered manager then took appropriate actions to rectify this.

The provider had made a number of improvements since our last inspections to redecorate and refurbish rooms and communal areas. Appropriate checks of the premises and equipment were in place.

Personal emergency evacuation plans (PEEPs) were in place. These were used to advise staff about people’s needs in the event of evacuation from the building. PEEPS were detailed and included challenges people faced such as mobility, confusion and risks posed by creams. Fire drills were taking place as scenarios with full evacuation and any lessons learnt from this were taken forward. There had been a recent fire officer inspection with an outcome of a reasonable standard.

People felt safe and happy living at the home. They said safety measures such as room door gates and supportive staff contributed to this sense of security.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The recruitment process in place ensured appropriate staff were recruited safely. There was a dependency tool in place and staffing levels were proactively managed to meet people's needs, with adjustments being made to ensure extra support was there when people need it, by using such things as shorter shifts.

Staff were provided with training to meet people’s needs, which was promoted via the staff newsletter. Staff were encouraged to become champions in areas of care such as dementia and continence.

Relatives felt able to communicate with staff and described them as warm, respectful and approachable. Most felt staffing levels were sufficient.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service appeared clean when we visited. There had been issues with lack of housekeeping staff, but support had been provided by other staff to ensure standards were kept at acceptable levels. Deep cleans had been completed by maintenance staff with the owner’s support. The laundry had appropriate systems in place to ensure clothes were cleaned and returned to the right person. The kitchen was clean and had systems in place to ensure food was in date.

The provider did not always make sure that medicines and treatments were managed safely to meet people’s needs.

We found there were not protocols in place for all ‘as and when’ needed medication to give staff guidance on when and how to give this medication. Introductory sheets which detailed how people liked to have their medication did not specify when people had their medication given covertly in food. Charts to show where patches had been placed on people to ensure rotation were not in place for all patches. As staff knew people well, we did not identify any impact from this and identified it was more a record issue. The daily counts for medication were not always taking place, which had not been identified on the daily checks carried out by senior staff. This meant people were at risk of not receiving their medication as it was prescribed. Appropriate actions were taken by the registered manager to the concerns raised.