We carried out a review of the data available to us about Credenhill Court Rest Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Credenhill Court Rest Home, you can give feedback on this service.
Credenhill Court Rest Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home is registered to provide accommodation with personal care for up to 35 older people, some of whom are living with dementia. The accommodation is split across three floors within one large adapted building. At the time of our inspection, there were 30 people living at the home.
There was a registered manager in post who was present during our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
At our previous inspection in November 2017, we rated the service as 'Requires Improvement' and identified two breaches of the Regulations. These related to the need for consent and good governance of the service. At this inspection, we found the provider had made a number of improvements and was now meeting the Regulations. However, further improvements were needed in relation to the management of people’s medicines. These included the need for a clearer system for recording the application of people’s topical medicines.
People felt safe living at the home. Staff had received training in, and recognised, their individual responsibilities to protect people from any form of harm, abuse or discrimination. The risks to individuals had been assessed, recorded and kept under review. The provider maintained safe staffing levels at the home, to ensure people’s needs could be met safely. They completed pre-employment checks on prospective staff to ensure they were safe to work with people. Measures were in place to protect people, staff and visitors from the risk of infections.
Before people moved into the home, the management team carried out a formal assessment of their individual needs and requirements to ensure these could be effectively met. Staff and management understood the need to avoid any form of discrimination when planning or delivering people’s care. Staff received induction, training and ongoing support to help them fulfil their duties and responsibilities. They helped people to choose what they ate and drank on a day-to-day basis, and promoted a positive mealtime experience for people. Staff played a positive role in monitoring people’s general health and helping them to access healthcare services. The provider had taken steps to adapt the home’s environment to meet people’s needs. Staff and management understood and promoted people’s rights under the Mental Capacity Act 2005.
Staff treated people with kindness and compassion, and had taken the time to get to know people well as individuals. People were supported to express their views about the service. Staff understood and promoted people’s rights to privacy and dignity, and helped them to maintain their independence.
The care and support provided was tailored to people’s individual needs and requirements. People's care plans were personalised and read by staff. The management team had assessed and addressed people's communication and information needs. People had support to pursue their interests and participate in a variety of stimulating and enjoyable activities. People and their relatives knew how to raise any concerns or complaints about the service, and felt comfortable doing so. People's preferences and choices for their end-of-life care were discussed with them and, where appropriate, their relatives, in order to meet these.
The provider carried out audits and checks to monitor the safety and quality of the service provided. The registered manager had a good understanding of the requirements associated with their registration with CQC, and spoke with commitment about people's care and quality of life. People, their relatives and community professional described positive relationships and open communication with the management team. Staff told us they had the management support and direction they needed to succeed in their roles. The management team took steps to maintain and develop links with the local community to benefit the people who lived at the home.
The inspection took place on 20 and 21 November 2017. Day one of the inspection was announced, and day two was announced.
There was a registered manager at this service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered providers and registered managers are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
At our previous inspection on 8 March 2017, we rated the service as Good overall, but found the key question of well-led required improvement. At this inspection, breaches of Regulations were identified. These were in relation to the need for consent and good governance.
The provider's recruitment process had not always been followed. which meant there was a risk of the provider employing unsuitable staff to care for people.
Although individual risk assessments were in place which guided staff in how to safely meet people's needs, these were sometimes contradictory and unclear. Medicines had not been audited to make sure these were all accounted for and had been administered safely.
The principles of the Mental Capacity Act were not always adhered to in regard to allowing people with capacity to make unwise decisions, should they choose to do so. Where restrictions were in place for people who lacked capacity, the best interest decision-making process had not always been followed.
The provider's systems for monitoring the quality of care provided to people had not been used to detect and remedy shortfalls in the service. People's care records contained inaccurate and out-of-date information, which meant it was sometimes unclear what people's needs were and how they were to be cared for.
There were enough staff to meet people's physical and emotional needs. Staff understood their roles and responsibilities in regard to protecting people from harm or abuse and in reporting any concerns about the same.
Consideration was given to protecting people from the risk of infection. People enjoyed a variety of different foods and drinks and were given choices. People were supported to maintain their health and access healthcare professionals, as required.
People were able to enjoy their individual hobbies and interests, as well as being given opportunities to develop new interests. People knew how to raise a complaint or give feedback, and this was acted on. People's changing needs were responded to.
People continued to enjoy positive and respectful relationships with staff. People's independence and dignity were promoted.
There was a positive and inclusive atmosphere and culture within the home. Links had been established with the local community for the benefit of people living at Credenhill Court. Staff felt valued and motivated in their roles and about their daily practice.
We undertook this comprehensive inspection to check that they had followed their action plan and to confirm whether they now met legal requirements.
This inspection took place on 8 and 9 March 2017 and was unannounced.
Credenhill Court Residential Home provides accommodation and personal care for up to 35 people, some of whom are living with dementia. At the time of our inspection there were 30 people living at the home.
There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated regulations about how the service is run.
At this inspection we found the registered provider was no longer in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 that we identified during the last inspection. These were in relation to how people were being deprived of their liberty, dignity and respect, person centred care and governance of the service.
Quality assurance systems were in place. There was a clear drive to improve the care and support for the people that lived there. Systems needed to be in place for longer to assure us that they were an integral and sustainable part of the service.
People were kept safe from harm. There were sufficient staff on duty to keep people safe and respond to people’s health needs at the times when they needed support.
People were treated with dignity and respect. Staff had formed positive relationships with people and treated them with kindness.
People were supported by staff that had the skills and knowledge to understand and meet their needs. Staff had access to on-going training and support to meet people's specific health and wellbeing needs. Staff felt that they were able to contact the registered manager at any time if they needed support or guidance.
People received the appropriate support to maintain healthy nutrition and ensure people’s specific dietary needs were catered for.
People were supported to access health and social care services to maintain and promote their health and well-being when needed.
Staff were only recruited once all checks had been made to make sure they were suitable to support and care for the people living in the home.
People received their medicines safely. Medicines were ordered, stored administered and disposed of safely.
People were given support to make choices and decisions about their care and support. Where people could not make specific decisions themselves these were made in their best interests by people who knew them well.
We undertook this comprehensive inspection to check that they had followed their plan and to confirm whether they now met legal requirements.
This inspection took place on 5 and 7 July 2016 and was unannounced.
Credenhill Court Residential Home provides accommodation and personal care for up to 35 people, some of whom are living with dementia. At the time of our inspection there were 33 people living at the home.
There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated regulations about how the service is run.
At this inspection we found that the registered provider was no longer in breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. However we found breaches in Regulation 17 in relation to the management and governance of the service, Regulation 13 in relation how people were being deprived of their liberty Regulation 10 in relation to dignity and respect and Regulation 9 in relation to person centred care. These shortfalls in the service are described throughout all sections of this report.
There was no effective leadership in the service. There were no quality assurance systems in place and the registered manager had not identified the concerns that we identified during the inspection. There were no clear actions planned or taken to improve the care and treatment that people received. We had concerns in relation to how the service was managed.
People were not always kept safe from harm. Staff were not deployed in a way to keep people safe or to respond to people’s health needs at the times when they needed support.
People were not always treated with dignity and respect.
People did not receive the appropriate support to maintain healthy nutrition and people’s specific dietary needs were not always catered for.
People were not always supported to access health and social care services to maintain and promote their health and well-being when needed.
People did not have opportunities to engage in their hobbies and interests.
Staff did not start working with people until checks had been made to make sure they were suitable to support and care for the people living in the home.
People did receive their medicines safely. Medicines were ordered, stored administered and disposed of safely.
This inspection took place on 10 November 2014 and was unannounced. The Credenhill Court Rest Home provides nursing care for up to 35 people. There were 32 people living at the home when we visited and there was no registered manager in post. The previous registered manager left on 9 May 2014. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.
People told us they felt safe. Staff knew what to do if they had a suspicion of abuse.
Staff had the information to keep people safe. However, not all plans were reviewed regularly. People told us that staff were kind and compassionate towards them. We saw that the staff talked to people respectfully although some of the phrases used could have been less directive.
We saw that there were enough care staff available to meet people’s needs. Training for staff was ongoing so that they would be aware of the latest ways for meeting people’s needs.
We saw that people’s medicines were managed so that they received them safely.
The deputy managers were clear about the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguarding’s (DoLS). However, reviews as to whether or not people needed to be subject to a DoLS had not taken place. This meant that the provider could not be sure that all steps had been taken to protect the rights of those people.
People had access to medical professionals should they need to. People’s records showed when and why visits happened. However not all records were maintained fully. This meant the provider could not be sure that appropriate had taken place to ensure that the person’s needs were met.
We talked with the deputy managers who told us that the provider did not regularly visit the service. There were no records of any visits that would have showed that the provider assessed whether the service was meeting people’s needs.
There were no effective means of identifying trends in accidents and incidents. This meant that risks to people may not have been identified and ways to reduce those risks put into place.
There was no evidence that the provider had sought people’s views of the way the service supported them. Records of visits by the provider or analysis of surveys could not be found.
You can see what action we told the provider to take at the back of the full version of the report.
Most people told us that they felt able to raise any issues with the manager or staff should they have any concerns. Staff spoke of their awareness of how to keep people safe from harm. Staff told us about the training that the home had arranged for them to attend so that they would recognise abuse and how to report it.
People told us that staff were usually available when they needed help. They said that the staff were friendly and always acted professionally. One person said, 'The staff are really very good' and another said, 'Staff are pretty good'.
The provider had developed a system whereby they can monitor how well the home was meeting the needs of the people who live there.
We spoke with the three visitors who were at the home to visit their family members. People were positive about the care and support at the home and felt involved One person remarked, 'They care about me too'. Another person told us that their relative, 'Always looks nice, they are always wearing their own clothes which are always clean'.
The care records contained detailed information about people's care needs and showed that the staff arranged the health care people needed.
The service had clear information available about the action to take if a person was at risk of harm due to abuse or neglect. Staff were trained so they would understand the correct procedures to follow if they needed to report any concerns.
There were suitable procedures for staff recruitment which included obtaining the required information about new staff before they started work.
There was information for people about how to make a complaint. People told us they would have no fears about raising anything they weren't happy with. A visitor told us they were very satisfied with how staff had dealt with something they had asked to be improved.