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 good. 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 the legal regulations in relation to safe care and treatment, premises and equipment, and safe and effective staffing.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a proactive and positive culture of safety based on openness and honesty. During our first visit, we shared feedback about concerns that posed a risk to people using the service, including concerns around medicines management and safe movement and handling of people. On our second visit, not all these concerns had been rectified or acted upon by the management team. The registered manager told us they did not have a complaints log in place. We were told this was because the last complaint to the service was made two years ago. We had received intelligence of a complaint raised with the service in December 2024 by a visiting professional, but this was not recorded or investigated and no outcomes recorded in line with the service’s complaints policy. When checking a person’s daily records, we noted an unwitnessed cut to leg, which the manager was informed of. When we checked accident and incident logs for December 2024 this was not recorded on the logs. This did not allow for investigation and monitoring of incidents and feedback that could be used to improve the service.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. We received feedback indicating the registered manager did not respond to attempts made to review an action plan for the service.Some partners provided feedback that it can sometimes be difficult to contact the service, and they were not always assured the service had listened and acted upon advice and information shared. Safety and impact during admittance to the service was not always considered. During our assessment a person was admitted to the service. This person was admitted during a time the refurbishment of the downstairs lounge was in progress and all people at the service were being cared for in the communal dining room. We observed this impacted upon space available to people at the service, communal activities due to limited space and the free movement of people at the service during the time the main lounge was not accessible.

Systems in place did not operate effectively to prevent abuse or neglect of people, or to ensure these were reported and investigated by the appropriate authorities. The service had a safeguarding log in place, although not all safeguarding concerns were recorded on the log and reported to the safeguarding team by the service. We found several safeguarding concerns related to medicines administration errors. For example, two people had missed their pain medication which was a controlled drug. We discussed with the registered manager that this had not been reported prior to our discussions, the registered manager reported these concerns to the safeguarding team. We were made aware of a safeguarding concern raised by visiting healthcare professionals. Although this was investigated and closed by the local safeguarding team it was not recorded on the services safeguarding log. The service was not completing any analysis of safeguarding events to allow them to identify any themes or trends. The service had recently reviewed their safeguarding policy, and staff had all attended safeguarding training; staff told us they would be confident in reporting any safeguarding concerns. While policies and staff training were in place, it had not resulted in good quality safeguarding processes. We were therefore not assured of the effectiveness of these policies and training to ensure concerns were acted on appropriately.

The service did not work well with people to understand and manage risks. They 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 observed a number of incidents of staff providing unsafe movement and handling of people. Movement and handling observed was not in line with people’s risk assessments and we observed staff drag lifting people and not providing or using assessed equipment with people. We also observed staff using equipment to transfer people that they were not assessed as requiring and they did not have the relevant documentation and risk assessments in place for. We found people were not safely supported with their mental health. For example, we reviewed the care plan for one person who was known to become agitated, and we found no detail about how staff should support them. This person had been prescribed with medication to be used “as and when” required to manage their agitation levels but there was no guidance for staff on when to administer this. Another person’s care plan recorded a person needed support from staff with food. When we checked daily recordings, we found they had not been supported to eat in line with their support plan.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. We found concerns with the environment. Furniture and carpets were worn and required replacement, a bath lift and a stair lift were out of use. We observed a trolley containing cleaning products that could be harmful to people including bleach, left unattended in a corridor and accessible to people living with dementia. On our first day of assessment and part of the second day assessment, the kitchen door lock was broken, and the kitchen was accessible to people living with dementia. During our first onsite visit we observed people accessing the kitchen when the cook had left for the day. This put them at risk of harm in the unsafe kitchen environment. We also received feedback from a relative this concern had previously been raised with the management team as a concern and no action was taken. We found self-closing brackets on two fire doors were broken. The service did have an action plan in relation to maintenance and improvements of the home. However, this action plan did not include all the concerns we observed and had not resulted in improvements being made in a timely way. During our assessment, the provider started the refurbishment of the ground floor including decorating, replacement of worn flooring and the intended replacement of some furniture.

The service did not always make sure there were enough qualified, skilled and experienced staff. The registered manager told us they calculated staffing levels by considering people’s care needs. However, we did not see enough staff deployed around the service. At times we observed no staff presence in communal areas and this impacted people receiving support in a timely way. We observed people walking around the service for extended periods of time without any staff to engage and encourage inclusion in ongoing activities or offer any alternative engagement. During our visits we had to actively seek staff to support people, and this included support with meal provision, personal care tasks and continence. We were therefore not assured that the manager’s calculations of staffing levels were suitable. Staff had been trained on how to help people move safely; however, we observed unsafe practise from staff and were not assured that staff are skilled despite training provided. We relayed this to the management team. The management team discussed our observations with staff but did not revisit any training or competencies with the four staff we observed concerns with. Despite our concerns with staff’s deployment, training and competences all staff we spoke to told us they felt enough staff was on duty and they had sufficient time to provide support and complete tasks expected of them. We saw evidence of regular supervisions with staff at the service and all staff told us they felt well supported, sufficiently trained and could seek support from management if they required it.

The service 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. During our visits, we found the service had an unpleasant odorous smell that was evident throughout the building on all of our visits. We found a number of hand sanitizers and soap dispensers to be empty on the ground floor. We found soiled laundry in exposed red bags on the laundry floor. This risks clothing contaminated with bodily fluids being exposed to other items and staff working in the laundry room. We found dirty stained sheets in use on a large proportion of beds and a damaged mattress protector which could not easily be cleaned. We found dirty laundry on a fabric chair in a bedroom. The service had received an external assessment of their infection and prevention practises and concerns had been identified; although these were known to the provider, we continued to find these same concerns during our visits.

The service did not make sure medicines and treatments were safe and met people’s needs. Controlled drugs legally require more advanced management than other drugs, due to the risk of harm and abuse. We found concerns with the signing in, checking stock, dealing with medicine spillages and returns to pharmacy. We found people were not receiving their medication as recommended. For example, people had been given paracetamol for pain relief but were at risk of overdose as the prescribed four hours gap had not been followed. We found other concerns including, adjustments of medicines recorded without staff recording why the medicine had been altered. The stock amount of medicines were recorded, but actual balances of medicines were incorrect when we checked. We found prescribed creams were not stored and recorded in line with current standards. Some people required ‘as needed’ medicines, but staff did not always have clear guidance on when these medicines were needed. They also did not clearly record why they had provided these medicines. The service had a recently reviewed medicines policy in place and staff had received medicines training. However, the availability of policies and training had not resulted in safe medicine management.