Crown House Care 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 means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for this newly registered service. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, and the ways people’s medicines were managed.

This service scored 34 (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.

Following a number of falls for people in the service, the provider had been given advice by an Occupational Therapist to not use the hoist to assist people up from the floor in the first instance. This was because using the hoist in the first instance could disguise people’s injuries. However, despite this advice being given on 2 separate occasions, staff had still used the hoist in the first instance when supporting a person from the floor. Although there was no evidence people had experienced harm as a result of the lack of guidance, there was a risk people may not receive safe care and treatment.

The provider had a falls decision tree in place; however, this did not include the process staff should follow when supporting a person up from the floor.

People told us they felt safe and happy living at Crown House Care Home, and relatives echoed this feedback.

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

Some concerns were raised during the assessment of how well the service worked with stakeholders when a person’s needs were changing.

The service mostly made referrals to health partners when a person became unwell, or needed additional support, such as the with wound dressings completed by the district nurses.

Staff told us people’s changing needs were communicated at every handover, which took place before the start of each shift.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Where people had experienced a cognitive decline, their rights under the Mental Capacity Act 2005 were not always upheld. One person was at risk of being deprived of their liberty.

Where people required support with the safe management of health conditions, the provider was unable to evidence this was always completed in line with the person’s care plan. This exposed people to an increased risk of harm. As a result of concerns identified during this inspection, we raised 2 safeguarding alerts to the Local Authority.

Several accidents had occurred within the service, however the provider had not always shared these with the required professional bodies, to ensure openness and transparency.

Staff had completed safeguarding training and understood the conventional signs of abuse.

The provider did not always work well with people to understand and manage risks.

Risks relating to people were not always assessed and managed appropriately, this meant people were exposed to an increased risk of harm.

Where people took medicines which increased the risk of the bleeding following a fall, no risk mitigation had been put in place. This meant staff did not have clear guidance in people’s care plans and risk assessments to enable them to take action in this event, to keep people safe.

Significant concerns were identified during our assessment in regard to the safe management of diabetes. Some people required their blood sugar levels to be monitored, which staff were completing. However, staff had not had the correct training to be able to undertake blood sugar testing. There was no clear information in place to ensure staff knew people’s safe blood sugar ranges, and the action which needed to be taken if a person’s blood sugar level was outside of these safe ranges. We addressed these concerns immediately with the provider, and the provider took action.

Where people needed support in monitoring their skin integrity, information to support staff to be able to complete this monitoring was not in always in place, and this placed people at increased risk of skin breakdown. People who required additional equipment to help maintain their skin integrity did not always have this clearly documented both in their care plan and their risk assessment.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Concerns about the safety of the environment had not been acted upon in a timely manner by the provider. A fire risk assessment had identified a number of significant concerns with the premises in October 2023, such as fire doors which did not close properly, missing smoke sensors in high-risk areas, and a lack of compartmentalisation of areas of the building, however these had not been remedied prior to our inspection. This posed a significant risk to people’s safety.

Personal Emergency Evacuation Procedures (PEEPs) lacked significant detail to support staff to be able to evacuate the premises in the event of an emergency, and we identified there was no equipment in place at the time of the inspection to enable staff to support people downstairs to ground level. This meant people would not be able to easily and safely leave the building in an emergency.

The provider’s evacuation policy conflicted with information contained within the Fire Risk Assessment and some of the information contained within the PEEPs.

We shared our concerns with the Fire and Rescue Service, who went out to complete an assessment and issued the provider with an action plan to complete essential works. We also addressed these concerns with the provider, who took actions to obtain equipment to help people evacuate the building, and contracted fire specialists to start on remedial works. The Local Authority compliance team have also offered support in the re-writing of PEEPs.

Following the inspection, the provider told us they had undertaken work to improve the safe management of fire, including purchasing new equipment to aid evacuation, work to rectify any defects with fire doors and fire safety systems, and worked with Leicestershire Fire Service.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

Staff members undertaking specific healthcare tasks had not completed training in Generic Delegated Healthcare Tasks, as per the Leicester, Leicestershire and Rutland Framework for Integrated Personalised Care. Staff had undertaken blood sugar finger prick tests, instilled artificial tears and applied steroid based creams without sufficient training or competency assessment. This meant staff were providing care and treatment to people who had specific health conditions or needs but had not received training or competency checks to ensure they had enough skills, education and knowledge to undertake the tasks required.

Staff had not completed all training detailed in the provider’s training policy. A large number of staff had missing training in areas such as Health and Safety Awareness, record keeping and oral health. Some training records for staff were not provided, and we therefore could not be assured these staff members had received the correct training.

Whilst supervisions had been completed with staff, these were identified to be basic, repetitive and did not follow the provider’s supervision policy. This was a missed opportunity to discuss professional and personal development with members of the staffing team.

The provider’s staffing dependency tool contained incorrect calculations, did not provide for night-time staffing requirements, and recorded generic assumptions on tasks to be completed, instead of a personalised breakdown of each person’s care needs. This meant the provider could not be certain of the precise numbers of staff required to meet people’s needs.

People and their families told us there were enough staff to meet people’s needs, and people said they did not have to wait for long if they needed assistance.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

During the inspection, we observed some staining on 1 person’s pillows and duvet. Whilst the registered manager completed mattress audits, this did not include a review of people’s bedding. We raised this with the registered manager, who immediately removed the stained bedding and replaced it with clean bedding.

A number of taps around the service had a heavy build-up of limescale, which increased the risk of the spread of legionella. The provider advised they were aware of this issue and were in the process of organising replacement taps throughout the service.

Staff had access to sufficient quantities of Personal Protective Equipment and knew when this was required to be worn.

The general environment was kept clean and tidy. The housekeeping team had instructions on which cleaning products to use for each type of bodily fluid, to ensure they were able to sufficiently clean and sanitise the environment to prevent the spread of infection.

Following this inspection, the provider told us they have received an Infection Prevention and Control (IPC) inspection from the Local Authority, and had scored 99% compliance.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The inspection found a significant number of issues around the recording of medicines. Staff had applied creams to a person without these creams being prescribed and recorded on the person’s Medicine Administration Record (MAR). Where other people had been prescribed creams for staff to apply, Topical Medicine Administration Records (T-MAR) had not always been completed with information for staff on where each cream should be applied to the person’s body.

Where people were prescribed ‘as required’ medicines, protocols were not in place to guide staff on how and when to offer or administer these medicines. MAR charts evidenced people were receiving ‘as required’ medicines on a regular basis. When these medicines had been administered by staff, for example, for ‘as required’ pain relief, there was no record of where the person was experiencing the pain within their body, and there was no follow up check completed by staff shortly after the administration to check the painkiller had worked. This placed people at risk of being overmedicated and not having their pain sufficiently managed.

Where MAR charts had been handwritten by staff, they did not always include all necessary information to support the safe administration of the medicine, including the dose which should be given, or the strength of the medicine. We also identified a number of entries made by a staff member were not validated. This meant the provider could not be assured the details had been accurately transcribed from the prescription label and placed people at risk of receiving their medicines incorrectly.

Where people had been prescribed transdermal patches for pain relief, staff had failed to record vital information on the Transdermal Patch Placement Chart, which meant there was not enough information available to staff to guide them to administer these patches safely.

Where blood thinner doses were amended, staff had been accepting these verbally over the telephone from the GP surgery and handwriting the new dose down on some paper. This placed people at risk of receiving an incorrect dose of medicine, and meant the provider did not have oversight of the safe administration of medicines. We raised this as a concern during the inspection, and the provider took immediate action to ensure all doses were communicated in writing moving forward.

During the inspection, we raised our concerns regarding medicines with the Local Authority, who arranged for a medicines specialist to go out to the service to undertake a full medicines audit.