You are here

Archived: Crawfords Walk Care Home Inadequate

The provider of this service changed - see new profile

Following a recent review of Crawfords Walk Care Home, the report below was published. We will update the information on this page to reflect this report shortly.

Inspection Summary

Overall summary & rating


Updated 28 September 2016

This inspection was carried out on 8 and 9 August 2016 and was unannounced.

Crawford’s Walk nursing home comprises of four purpose-built units in the Hoole area of Chester. The service is owned and operated by BUPA care homes. Northgate is a unit for people with enduring mental health illness issues, Watergate and Eastgate are units for people living with dementia and Bridgegate unit provides support for those with physical health needs.

The service does not currently have a registered manager in place. 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. The service has a manager in place who has recently applied for the registered manager’s position.

A comprehensive inspection of the service was completed on the 16 and 17 May 2016 and we found that the registered provider was not compliant with the Health and Social Care Act 2008 (Regulated Activities) 2014. We issued the registered provider with a warning notice and told them to be compliant by the 3 October 2016. We conducted this focused inspection due to concerns that we had received following our last inspection regarding the safe care and treatment of people living at the service. We looked at the safe and well led domains. We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014. The registered provider submitted an action plan within 18 hours of our inspection visit highlighting the actions that would be taken to address immediate areas of concern we raised regarding the risks to the health, safety and welfare of people living on Watergate unit. You can see the action we have told the provider to take at the end of the report.

People on Bridgegate unit told us that they felt safe living at the service. Staff had an understanding of different types of abuse, such as financial, physical and verbal abuse. The registered provider had recently shared information with staff as to how to safeguard people from abuse and how and who to report concerns too. However, we identified institutional practices in place between the day and nights shifts on Watergate unit. People rights and choices had not always been respected and this had not been identified or addressed by the registered provider.

Areas we raised related to poor and restrictive practices that had not been identified or addressed. Mobility aids such as walking sticks and Zimmer frames were placed out of peoples reach. The environment had not been adapted to aid and support people living with a visual impairment. This meant people’s movements were restricted in the environment and the registered provider had not recognised or addressed cultural restraint within the service.

Staffing levels were not sufficient to meet the needs of people supported. Staff sickness and cover had not been reported and staff told us that it was usual practice to work short staffed on night duty at the service. People were left unsupported and not observed at times and this led to a number of situations were inspectors intervened to prevent accidents and incidents occurring. This meant that people had been placed at risk of harm due to a lack of staff, reduced observation and support.

Risks to people health and safety were not always identified by the service. We found on Watergate unit that the kitchen and sluice room doors were left open and accessed by people living with dementia at the service. Some people were unable to independently call for help or support from their bedrooms. There were no alternatives other than night time checks to ensure that people were safe and observations showed that these were not completed on a regular basis. This meant that people were placed at increased risk of harm and cross

Inspection areas



Updated 28 September 2016

The service was not safe

Insufficient checks were completed on pressure relieving equipment.

Staffing levels on Watergate unit were not safe. People were not protected from the risk of harm.

Staff knowledge and understanding of fire safety and emergency evacuation procedures was poor.


Requires improvement

Updated 9 July 2016

The service was not always effective

Records to evidence that consent to care and treatment and best interest�s decisions made were not in line with the requirements of the Mental Capacity Act 2005.

Staff received regular supervision and training to support them with their roles. However, it was clear that not all the training was effective as staff had a varied understanding of the principles of mental capacity or DoLS requirements.

The mealtime experience was relaxed and pleasant. People told us how much they enjoyed the food and they were offered choices at mealtimes.


Requires improvement

Updated 9 July 2016

The service was not consistently caring

Staff on Bridgegate did not always treat people with dignity. People�s personal appearance was not always maintained.

We saw people being acknowledged and their privacy being respected as staff were discreet in asking if people needed help.

Staff understood the importance of providing dignified and respectful end of life care to people.


Requires improvement

Updated 9 July 2016

The service was not always responsive

Care plans did not accurately reflect the care and support that people required. Daily records were not completed in a timely manner or in full detail.

Supplementary charts or daily records were not checked or monitored in order to analyse and utilise the information recorded.

People and their relatives knew how to complain and were confident their complaints would be resolved.



Updated 28 September 2016

The service was not well led

Cultural, institutional and restrictive practices had not been recognised and addressed at the service.

The environment did not always meet the needs of people supported. There were no adaptations or equipment in place to support people living with a visual impairment.

People were not always treated in a respectful and dignified manner. This has not been recognised or addressed by the registered provider.