Crescent House

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 means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment this key question was rated Good. At this assessment, the rating has changed to Requires Improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 56 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider had systems in place to record and review accidents, incidents and safeguarding concerns. These were investigated, and actions were taken to reduce risks. For example, records showed six medicine-related incidents had been reviewed in the last three months. However, there was no evidence that outcomes or learning from these reviews had been shared with all staff to promote consistent improvement.

The digital visitor sign-in system had not always been reliable, and when the screen failed, no alternative process was clearly signposted. This issue had occurred before, but lessons were not used to prevent recurrence. Clear instructions and daily checks were only introduced after it was highlighted during the assessment.

Some staff said they felt able to raise concerns and that the provider responded when issues were reported. However, some staff said learning from incidents was not always communicated effectively or embedded into day-to-day practice. This meant learning remained largely reactive rather than proactive. Strengthening communication and feedback mechanisms across all staff groups would help create a more open and consistent culture of safety and continuous improvement.

The provider worked with people and healthcare partners to establish and maintain safe systems of care in which safety was managed and monitored.

There were systems in place to support safe admissions, transfers and discharges. People moving into the service had assessments completed before admission, and information from hospitals or community teams was used to plan care.

People and relatives said they felt supported during transitions. One relative told us their family member was, “Admitted on a non-weight-bearing pathway and it’s worked out well, includes physio.” Families described staff as approachable and said their relatives had settled well into the home.

Records showed the provider worked with other professionals to ensure continuity of care. Care files contained evidence of regular contact with district nurses, dietitians, GPs and therapists.

The systems for managing admissions, discharges and transitions were effective and ensured people’s care remained safe and coordinated.

The provider worked with people and healthcare partners to understand what being safe meant to them and how best to achieve this. Staff focused on improving people’s lives while protecting their right to live safely, free from abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and took appropriate action to keep people safe.

People and relatives said they felt safe living at Crescent House. One person told us, “Yes, I feel safe… there is always someone around.” A relative said, “The staff have been very friendly since the very first. I have never had any reason to raise a concern.” Another commented, “The carers are kind, personable; they have a joke and smile.” Feedback showed people trusted staff and felt comfortable raising any concerns.

There were clear systems for reporting and acting on safeguarding concerns. Staff understood their responsibilities and described how they would report any poor practice or suspected abuse. Records confirmed that safeguarding referrals were made appropriately and reviewed to ensure suitable action had been taken.

Staff were also aware of people’s rights under the Mental Capacity Act and understood that any restrictions must be the least restrictive option necessary to keep people safe. This helped ensure that safety and dignity were balanced when supporting people’s care.

DoLS authorisations were in place where required, and conditions were followed. Applications and renewals were tracked to ensure these remained current.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care that was fully safe, supportive or enabled people to do the things that mattered to them.

Systems were in place to assess and mitigate risks to people’s health, such as Malnutrition Universal Screening Tool, Waterlow assessment, falls and choking assessments. However, these were not always accurate or reviewed in line with people’s changing needs. For example, a person with wound, didn’t have a waterlow assessment in place. This meant that information used to guide care was occasionally inaccurate. Families said they were not always informed of changes to care plans, reducing opportunities for them to contribute to managing risks.

There was some good practice. Personal evacuation plans were up to date, ensuring people could be supported safely in an emergency.

Although staff understood people’s needs and acted safely in practice, care records and risk reviews did not always reflect this. Strengthening record reviews and involving families more consistently would help ensure risks are always clearly identified and managed.

The provider did not always detect and control potential risks in the care environment. They did not always make sure that equipment, facilities, and safety systems were proactively maintained to support the delivery of safe care.

Some environmental issues were identified during the inspection, including a rusty stand aid, areas of lifting or damaged flooring, and a loft hatch left open. The provider told us that the loft door had been left open temporarily as part of an ongoing air conditioning installation project. Although this was understood to be a work in progress, it still presented a potential safety risk and should have been secured when not in use. The provider gave assurances that repairs and replacements would be completed promptly. This indicated that routine environmental audits were not always effective in identifying and addressing risks in a timely way.

Health and safety records showed that some key checks and maintenance tasks were not consistently evidenced at the time of the inspection. However, evidence was later provided to show that a health and safety compliance audit was carried out in August 2024, which included elements relating to fire safety and provided some reassurance. This did not replace the need for a full external fire risk assessment, which the provider has since arranged. Weekly, fire alarm tests were carried out, but some records were missing. Weighing scale calibration had also been completed internally for a few years, and external contractors were now booked to carry out the checks.
 

Records showed that the last face-to-face fire training for staff took place a few years ago. The provider had arranged new in-person training to ensure all staff were updated on evacuation procedures and fire safety responsibilities.
 

The digital visitor sign-in system had not always been reliable. On occasions when the screen failed, there was no clear signage to direct visitors to use the paper log instead. This created a potential gap in knowing who was in the building in the event of a fire or emergency evacuation. Following our feedback, the provider introduced clear instructions for visitors and added daily checks of the system’s functionality. These actions reduced the immediate risk and improved oversight of fire safety procedures.
 

The home environment was generally clean, tidy, and free from clutter. The garden was well maintained and accessible, and clear signage supported orientation for people living with dementia. However, some maintenance, flooring, and safety issues had not yet been addressed, and although the provider assured us that remedial actions would be taken, the lack of consistent environmental oversight meant safety risks were not always identified or resolved in a timely manner.

The provider did not always make sure there were enough qualified, skilled and experienced staff who were effectively supported and supervised. Based on the provider’s dependency tool, staffing levels met the minimum requirement. However, deployment and support arrangements meant people did not always receive consistent or timely care.

Care staff were also expected to complete laundry and kitchen duties alongside their caring responsibilities. Some staff said this reduced the time available to support people. One staff member commented that “it’s hard to meet residents’ needs when so much time is spent washing up and doing laundry.”

Agency staff were used sometimes, but proper checks and inductions were completed before they started work. Staff described teamwork as good overall, and observations showed interactions between staff and service users were kind and caring.

The induction process required improvement. Newer staff said they had shadow shifts but did not always feel prepared for their roles or confident with routines on both units. Some described a lack of supervision meetings or practical supervision of the service and clear guidance, while others said they received help from colleagues when needed. Some new staff also said they were not always well supported by existing team members and felt they were placed on shift before they were ready.

Induction documentation was not always fully completed or signed, and risk assessments for staff starting work before DBS clearance were not adequate. We were not assured the process for allowing staff to work while awaiting a DBS check was sufficiently robust or that staff were informed of supervision arrangements or restrictions while awaiting their DBS results. We found there was no formal evidence these expectations had been discussed or understood by staff and where an Adult First check had retuned inconclusive staff had commenced in post without adequate control measures. Some staff were placed on shifts soon after induction, before demonstrating full confidence or competencies, indicating weaknesses in oversight and safer recruitment governance. Training records showed staff had completed the required courses, and there was no evidence of overdue refresher training apart from face-to-face fire training, which the provider had already arranged to update.

Although teamwork was generally positive and staff were kind and caring in their approach, gaps in induction, supervision and deployment meant oversight of staffing arrangements was not robust. This meant the risk that people would not always receive timely and coordinated care was increased.

The provider did not always assess or manage the risk of infection effectively. Although the environment was generally clean and free from unpleasant odours, some areas and practices required improvement to ensure consistent infection control standards.

Staff were observed using personal protective equipment (PPE) correctly during care tasks, and clinical waste bins were available throughout the home. However, several infection control risks were identified during the inspection. Porous flooring in a storage room and damaged wooden serving trays in the kitchen posed potential hygiene risks. Ice build-up in a freezer and a lack of regular kitchen audits showed poor oversight of food safety and cleanliness. These issues were raised during the inspection, and the provider confirmed that immediate action would be taken.

Hand sanitiser was accessible in communal areas.Staff said they were sometimes required to work across care, laundry and kitchen duties, which increased the risk of cross-contamination. The provider explained that this was a temporary measure while recruitment took place.

During a recent period when several people became unwell, the provider introduced appropriate precautionary measures, including room-based care and pausing activities. However, families were not informed at the time, meaning visitors could have entered the home unaware of the situation. The provider explained that a COVID-19 outbreak was briefly suspected but later ruled out and assured us that families would be notified promptly if similar precautions were introduced in the future.

Although staff followed infection, prevention and control procedures in daily practice, insufficient auditing, incomplete records, and the crossover between domestic and care duties meant the provider could not assure us that infection control systems were always effective.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Although systems for storage and general administration were well established, some records and processes required improvement.

Medicines were stored securely, and each person had their own drugs cupboard. Both cupboards and trolleys were locked, and the medication room was clean, organised and temperature controlled. A live monitoring system recorded room and fridge temperatures and was designed to send alerts if readings went outside safe ranges. However, some staff did not know how to access these records or that alerts were sent by email when temperatures exceeded safe limits. The provider explained how the system worked and assured us this would be reviewed with the team.

PRN protocols (as required) were missing on the first day of our inspection. Updated versions were provided later. When PRN medicines were administered, staff did not always record the reason or outcome, and refusals were not consistently documented.

During our review of the electronic medicines administration record (eMAR) system, we observed that some staff were not fully confident in its use, which increased the risk of recording errors. This was brought to the attention of the provider, who assured us that further training and review would take place.

Monthly medicines audits were being completed but focused on expiry dates and stock counts rather than observing practice or checking signs, MAR sheet documentations, PRN Protocols. One person’s Bisoprolol, which had been discontinued was still stored in the. This was removed immediately once identified.
 

Staff responsible for administering medicines were trained and assessed as competent, with annual rechecks in place. They understood the procedure to follow if a person refused medication and when to escalate concerns to a GP or pharmacist.

Overall, medicines were stored and administered safely, and people received their prescribed treatments as prescribed. However, insufficient auditing, incomplete PRN protocols and gaps in staff knowledge of the eMAR system meant medication safety systems were not consistently monitored to maintain best practice.