The Crown

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 we rated this key question requires improvement. At this assessment the rating has changed to 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 safeguarding.

This service scored 38 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. For example, we identified several incidents involving emotional distress and physical aggression recorded in daily notes, these had not been reported for managerial review, meaning learning and risk‑reduction opportunities were missed.

The service did not always maintain safe systems of care to manage risks people could experience or be exposed to. Safeguarding concerns were not always identified, and care plans did not always reflect people’s needs. However, the service worked with healthcare partners when they had identified concerns such as people experiencing ill or deteriorating health. For example, we saw evidence of the service sharing information regularly with the intensive support team.

The provider did not consistently identify or act on safeguarding concerns. Staff had used restrictive practices without sufficient governance, training or lawful oversight. We identified multiple records indicating restrictive practices had been used, staff confirmed this. These unplanned instances had not been reported to the local authority safeguarding team or CQC.

The provider did not always work effectively with people to understand and manage risks. Staff did not consistently provide care that was safe, supportive or aligned with what mattered to people. Care plans lacked sufficient detail and were not always consistent in guiding staff on how to support individuals with risks specific to them. For example, one person’s care plan stated they could experience emotional distress, however it did not describe how this distress might present or provide clear instructions for staff on how to respond. This placed people at risk of receiving unsafe or inappropriate support.

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.For example, we identified unsecured wardrobes in bedrooms, hot radiators without covers, hazardous substances accessible in the kitchen and fire doors with excessive gaps. The provider was responsive to our feedback and made arrangements to rectify a number of issues with the environment before the end of our assessment.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs. For example, we found one new staff member supporting a person with known risk behaviours had not completed the required training. Restrictive practices described by staff did not align with documented positive behaviour support guidance, increasing risk to people and staff. We found staff were not always recruited safely, for example, we identified records did not contain appropriate references or full work history.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. For example, Legionnaires disease management requires shower heads are cleaned and descaled at regular intervals, the provider was unable to produce records to confirm this was taking place. We found a dirty and scaled showerhead and water temperature records were not completed despite being required in the provider’s legionella risk assessment.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. For example, we identified topical medicines with illegible pharmacy labels. When required medicines did not always have appropriate protocols in place. Electronic medicines administration records did not match pharmacy label directions. This placed people at risk of receiving unsafe medicines.