Crimson Manor

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 Inadequate. At this assessment the rating has changed to Good. This meant people were safe and protected from avoidable harm.

At our last assessment we recorded breaches of legal regulations in relation to safe care and treatment, premises and equipment and safe and effective staffing. At this assessment we found the provider was not in breach of these regulations.

This service scored 72 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Systems were in place to record and review accidents, incidents, falls and safeguarding events. Records we reviewed were detailed, showing what had happened and actions taken. Monthly analysis considered themes and trends and demonstrated lessons learned.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Systems were in place to ensure people were safely transferred between services and information about their care and treatment needs went with them. This ensured people received continuity of care when moving either to hospital or another service.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Staff were trained and understood how to raise safeguarding concerns. Safeguarding records were well-completed and information was shared appropriately with other agencies, such as the local authority, in a timely way.

Staff had received training in Deprivation of Liberty safeguards (DoLS). DoLS ensure if a person is restricted in a way that deprives them of their liberty in a care home, it is only done when it is in their best interests, is necessary for their safety, and all other options have been considered.A DoLS tracker provided oversight of authorisations, ensured conditions applied to the DoLS were met and monitored the progress of applications.The provider responded promptly to the June 2026 Supreme Court judgment by redesigning its Article 5/DoLS assessment process, implementing new documentation and delivering staff training.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments were in place for people where required and we saw good evidence of involvement of other professionals following incidents. For example, when falls had occurred, referrals had been made to the falls team.

The provider did not always detect and control potential risks in the care environment.

The environment was clean, tidy and generally well maintained. Some areas of the home had been refurbished. Air conditioning and air purification and extraction systems were in place.Safety certificates were in place to ensure the safety of the building, equipment and technology.

We identified some environmental concerns on the first day of our assessment; most of which had been addressed by the second day. This included the removal of items from a corridor which is a fire escape route, correcting pressure relieving mattress settings to ensure they corresponded with people’s weights and fixing a broken window restrictor.

However, some issues remained. For example, one person's bedroom door did not display either a name or room number, making the room difficult to identify. This could present challenges in the event of an emergency evacuation where people need to be located quickly.

Individual personal emergency evacuation plans (PEEPs) were held electronically within care records and the provider’s emergency operating procedure confirmed these records could still be accessed in the event of an internet connectivity failure.Room numbers and location of rooms were not always included in the PEEPs, however, following our site visits, the provider confirmed this had been addressed.

On the first day of inspection, 2 staff were wearing open-toed footwear, which may not provide appropriate protection in a care environment. The provider confirmed this had been addressed as the footwear was not in accordance with their policy.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

A dependency tool was used to calculate safe staffing levels, which were monitored and reviewed weekly. Both registered managers provided on call support for staff out of hours and at weekends. Staff told us staffing levels were sufficient to meet people's needs and described good teamwork across the service. Staff maintained a presence around communal areas, checking in with people and responding to their needs.

Safe recruitment processes had been followed for a recently employed staff member. Records showed all staff were up to date with mandatory training and had completed competency assessments. The majority of staff were up to date with specialised training. Evidence showed staff received regular supervision.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was visibly clean and hygienic, and staff were observed wearing appropriate personal protective equipment (PPE). Hand sanitising facilities were readily available throughout the home, and records showed cleaning schedules were completed and monitored. Management told us cleaning standards were reviewed and challenged where necessary to maintain good practice. The service had also recently undergone an IPC inspection with the local authority and received positive feedback.

We observed several staff members with long nails, including acrylic or overlay nail coverings. IPC best practice guidance from the department of health and social care recommends short, clean fingernails free from nail products including artificial nails for safe and effective hand hygiene. The provider confirmed they have diverted from this guidance by allowing staff to wear acrylics and have checks in place to ensure nails are intact and a correct length.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines were stored safely and securely, and stock levels checked on the day of inspection were correct. People received their medicines in a timely manner with evidence of time critical medicines being given within safe intervals. Staff received medicines training and competency checks. Audits were carried out regularly and appropriate actions taken.