About the service: Crimson Manor provides accommodation, care and support for up to 20 people over 65 years old, including people living with dementia. The home provides permanent and short stay care. At the time of our inspection, there were 15 people living at the service.People's experience of using this service: People and relatives told us they felt the home provided safe care. However, during this inspection, we identified concerns in relation to the safety of the care provided.
We found the service had deteriorated since last inspection.
At this inspection, we found failings in the oversight, monitoring and management of the service and we could not be reassured people were always receiving safe care.
During this inspection, we found the service was in breach of regulations in relation to safe care and treatment, consent, person centred care and good governance. We made three recommendations in relation to management of risks to people’s skin integrity, falls and submission of statutory notifications.
The provider had policies and procedures to deal with safeguarding concerns and staff told us about signs of abuse they would report and how, however during this inspection, we identified safeguarding concerns in relation to people having bruises which had not been accurately recorded or fully investigated. We contacted the local safeguarding in relation to these.
We found the provider was not always managing risks to people’s care appropriately. The home’s buzzer system had been inoperative for several weeks before our inspection; the provider had put in place additional checks on people however, we could not be reassured they had taken all the reasonable steps in a timely way to manage the risks associated with people falling or people not being able to summon help. At this inspection, we could not be sure risks to people’s skin integrity were effectively assessed and advice from professionals always incorporated in the care plans and followed. The provider informed us they were aware of the guidance in relation to checking the temperature of the water in people’s baths and showers. They had the appropriate equipment fitted and were checking the temperature of the water every four weeks.
During this inspection, we found the home was not always free of malodours and we identified concerns in relation to infection control procedures. We shared our concerns with the local authority’s infection control team. There were areas of the home that required maintenance and we could not be reassured action had always been taken promptly.
We found people’s medicines were administered in a person-centred way. However, we found improvements were required in the recording of people’s prescribed creams and ‘as and when required’ medication as well as the information recorded during medication audits.
People were supported by staff who told us they were motivated and enjoyed their job. Staff felt supported by their management however at this inspection we found staff were not offered supervision as often as stated by the provider.
We found the quality of care plans was variable; some areas of people’s care plans were individuated, included their choices and preferences and met the needs of people using the service however, other areas lacked detail in relation to important areas of their care.
There was a regular and varied programme of activities at the home and people spoke positively about the activities they were involved in.
Feedback from staff and people was mostly positive and they felt the service was well-led. Relatives shared mixed views in relation to the management of the service. Our findings at this inspection indicate management’s oversight was not robust.
There were several audits in place however these had not always been effective in identifying the issues found at this inspection and in driving the improvements required.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection: At our last inspection the service was rated good. Our last report was published on 22 November 2016.
Why we inspected: This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received.
Enforcement: Please see the 'Action we have told the provider to take' section at the back of this report. Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up: We will continue to monitor the service closely and discuss ongoing concerns with the local authority, clinical commissioning group and safeguarding team.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk