Cressington Court 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 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 provider was in breach of legal regulation in relation to people’s safe care and treatment, medicines management and safeguarding.

This service scored 28 (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.

There was a system in place to enable staff to record when accidents and incidents occurred and the action taken. However, provider oversight and monitoring of accident and incident was ineffective, there was limited information to identify trends in how and when accident and incidents occurred, and no clear evidence of any of learning or action taken to mitigate this risk of reoccurrence.

Provider audits of service delivery showed repetitive shortfalls including record keeping, environment, medicines management, people personal finances or governance with token gestures such renewed governance arrangements which did not have any impactful improvements. The provider was reactive, meaning they could not anticipate potential problems or take opportunities to address issues before they arose.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

Feedback from some health and social care professional was the provider needed to make improvements and particularly key information about people and their needs required to be up to date and relevant. Staff shared knowledge verbally, however, a lack of reliable information would impact when people moved from the service to another health or social care setting.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. For some people the relevant safeguards were not in place, this included the Mental Capacity Act 2005 (MCA) not being followed, the MCA is in place to promote and safeguard decisions within a legal framework. During the assessment a safeguarding referral was made with the local authority due to financial concerns found.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. We found people were not involved in decisions about managing their risks, and staff did not consistently recognise or respond to changes in people’s needs. Care plans contained information left in draft or not updated. The provider could not be assured staff had access to the most pertinent information including people’s physical health needs, identified risks and guidance on how to manage these risks for staff to follow to prevent avoidable harm. We observed agency staff were not always aware of the needs of the people they were supporting and this placed people at risk of inappropriate or unsafe care.

The provider did not always detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care. We observed in the ground floor lounge, music being played excessively loud including a three-hour period where the nursery rhymes, baa baa black sheep and Mary had a little lamb being played repeatedly. On the first floor we observed people sitting in the lounge with no activities or interactions. We observed almost every chair in ground floor lounge and first floor lounge had pressure relieving cushions on, some with two stacked on one another. Nearly all the cushions appeared out of shape and were worn out. We could not find any evidence the pressure relieving cushions were targeted for specific people or any reason why the people would require pressure-relieving cushions, and this was not recorded in any of the care records. Inappropriate use of pressure relieving equipment including pressure cushions placed people at risk as the equipment can alter a person’s posture, reduce stability and increase the likelihood of sliding or adopting unsafe seated positions. This can contribute to skin damage.

Further observations included loud drilling and banging by maintenance staff with no consideration for people. We observed people with their hands covering their ears to try and block out the loud noises. On the first-floor, maintenance staff equipment was laying on floor causing a potential trip hazards to people. This included dust mats and tools outside people’s rooms.

The provider was not always aware of their responsibilities to have fully trained staff delivering care. During discussions with the inspectors the home manager confirmed they were unaware of the Health and Social Care Act 2008. We showed them the guidance for providers on meeting the regulations and read our regulation 12. The home manager confirmed they were not aware of regulation 12 and confirmed they had no knowledge of the Health and Social Care Act 2008.

Safe recruitment processes were in place with relevant checks of staff’s employment history, character, right to work, and checks with the disclosure and barring service (DBS).

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly. We observed the pressure relieving cushions were visibly dirty and had cracks which presented an infection prevention and control risk as they could not be cleaned effectively. In addition, the environment was dirty in places, with furniture visibly unclean and damaged. This posed an infection prevention risk because damaged surfaces cannot be cleaned to the required standard. We noted on day’s 1 and 2 of the assessment the windows to be dirty and appeared to have not been cleaned for a long time. We fed this back to the management, and they were cleaned by the time we returned for day 3.

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

The majority of medicines administration records showed medicines were given as prescribed, however, a small number of records were not completed to show if the medicines had been given. Therefore, it was not clear if the medicines had been administered as prescribed.

Records showed medicines were prescribed to be given at specific times, were given at the correct time.

Information to support staff to safely administer ‘when required’ medicines was not always correct. In addition, when people were prescribed 2 medicines for the same condition, such as constipation, care plans and protocols did not detail which medicine to give first. There was a risk people may not receive the most appropriate treatment.

Records did not always show thickener had been added to drinks for people at risk of choking; therefore, we were not assured the drinks were made correctly, which placed them at risk of choking.

When people were prescribed medicine patches, the manufacturer’s instructions to rotate the site of application were not always followed, increasing the risk of people experiencing side effects. Records for the application of prescribed topical preparations such as creams, showed they were not always applied as prescribed, this meant there was a risk people’s skin was not cared for properly.

Staff completed medicines training and had their competency assessed. Medicine related incidents were reported and investigated. Audits were completed; however, they had not been effective in identifying all of the issues found during this assessment.