About the service:

Crelake House provides accommodation with personal care for people over age of 65, who may also have mental health conditions, physical disabilities or are living with dementia. The service is registered to accommodate up to 27 people, and was providing personal care to 19 people at the time of the inspection. Any nursing needs were provided by community nursing services.

People’s experience of using this service:

People, relatives, staff and professionals all described improved safety systems at the service. Risks of abuse to people were minimised because improvements had been made to safeguarding systems and processes. Staff demonstrated a good awareness of each person's safety needs and how to minimise risks for them. Improvements had been made in the garden to make it safer for people to use independently. Paths had been cleared, levelled and grab rails fitted. Regular checks and servicing of equipment was undertaken to ensure it was working effectively. There were enough staff on duty at the right time to enable people to receive care in a timely way.

People were cared for by staff who had the skills and knowledge to meet their needs. They were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People were supported to access healthcare services, staff recognised changes in people's health, and sought professional advice appropriately.

People received personalised care from staff who knew what mattered to them. Staff developed positive, meaningful relationships with people, they were caring, compassionate and treated people with dignity and respect. Risk assessments and care plans were more detailed, personalised and up to date about people’s care needs. Significant improvements had been made in encouraging and supporting people to socialise more and pursue their interests and hobbies. A wellbeing co-ordinator worked with people to provide a variety of planned group and individual activities.

People's concerns and complaints were listened and responded to. Accidents, incidents and complaints were used as opportunities to learn and improve the service.

People, relatives, staff and professionals gave us positive feedback about the improvements made. Quality monitoring systems had improved and included regular audits, observation of staff practice and checks of the environment with examples of continuous improvements made in response to findings. However, some aspects of quality monitoring needed further improvement to demonstrate improvements are sustained over time. For example, in relation to consistency of daily records about eating and drinking, catheter care and repositioning.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection:

At the last inspection in May/June 2018 the service was rated Inadequate (report published on 8 October 2018). At that inspection we found eight breaches of Regulations across a range of areas. They related to safe care and treatment, staffing and skills, safeguarding, premises and equipment. Also, compliance with the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS); personalised care, quality monitoring systems and failing to notify the Care Quality Commission (CQC) about safeguarding concerns and accidents resulting in injuries to people. At this inspection the overall rating has improved.

Following the inspection, the Care Quality Commission (CQC) took enforcement action by imposing a condition on the providers registration. This required the provider to provide CQC with a monthly report outlining actions and progress towards making the required improvements. We also met with the provider on 2 October 2018 to hear about their improvements.

Why we inspected:

This service has been in Special Measures. Services that are in Special

This unannounced comprehensive inspection took place on the 31 May, 1 June and 12 June 2018. The acting manager was on leave when we visited and we arranged to return on 12 June to meet with them. The inspection was to follow up to see whether improvements had been made from the previous inspection in July 2017. The inspection was brought forward because we had received a number of concerns about safety and standards of care provided at the service.

Crelake House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Crelake House provides accommodation with personal care for people over age of 65, who may also have mental health conditions, physical disabilities or sensory impairments. Any nursing needs are met through community nursing services. The service is registered to accommodate up to 27 people, 23 people lived there when we visited. The home is a two storey building on the outskirts of Tavistock. Access to the first floor is by a stair lift. On the ground floor there are two lounge areas, one of which is a conservatory overlooking the garden and a library. People can access an enclosed garden area and walk around three sides of the building.

We had previously carried out an unannounced focused inspection of this service on 26 July 2017, in response to anonymous concerns raised with Care Quality Commission (CQC). At that inspection we looked at two areas, safe and well led. Both areas were rated requires improvement with a breach of regulations identified in relation to good governance. This was because people's care records lacked detail and increased risk of people not consistently receiving the care they needed. Quality monitoring systems were ineffective because increased risks related to pressure sores highlighted a lack of systems for checking people were regularly repositioned or that their pressure relieving equipment was at the right setting for their weight. Also, because there was no system in place for monitoring trends in relation to accidents and incidents, which meant opportunities to identify and take further actions to minimise risks may be missed.

Following that inspection we issued a requirement and received an improvement action plan from the provider about how they were managing those risks. This included working with the local authority quality monitoring team to make the required improvements.

Prior to that we had previously carried out an unannounced comprehensive inspection of this service in May 2016, and rated the service Good overall with no breaches. At that inspection we recommended that training and systems are put in place, to promote a more systematic approach to capacity assessment, in line with the Mental Capacity Act 2005 and its Code of Practice.

The service has a registered manager, who was on maternity leave. The deputy manager was the acting manager in day to day charge of the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

In the five weeks prior to the inspection, we were contacted anonymously by three people on five occasions raising concerns about the home. These included concerns about management and leadership of the home and allegations of bullying. Concerns were also raised about low staffing levels not enabling people’s needs to be met in a timely manner, high staff turnover and staff working long hours. Other issues raised included a perceived lack of support for new staff and about medicine errors. We followed these up with the acting manager and

We carried out an unannounced comprehensive inspection of this service on 23 and 31 May 2016. At that inspection, the service was rated ‘good’ overall. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Crelake House Residential Care Home on our website at www.cqc.org.uk.

On 25 July 2017, the Care Quality Commission (CQC) we received anonymous concerns about the home. Concerns were about night staffing levels and about people not having choices about the time they get up. Also, about people’s care plans being out of date, and about a person at increased risk due to lack of staff knowledge about pressure area care and equipment. Concerns were also raised about medicines management. When we sought feedback from community nurses about care at the home, they also raised a concern about staff not consistently following their advice about a person’s foot care and about cleanliness. An unannounced focused inspection took place on 26 July 2017 to follow up those concerns. This report only covers our findings in relation to these concerns.

Crelake House is registered with the Care Quality Commission to provide accommodation for up to 27 people who may require personal care. People’s health care needs are met through community health care services. When we visited, 21 people lived at Crelake House.

The service has a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People’s risk assessments and care plans lacked detail and did not provide detailed enough information for staff to provide safe care. However, care staff were knowledgeable about peoples’ care needs and how to manage them. For example, in relation to people’s moving and handling needs, skin care, regular repositioning and equipment. Some of the information about people’s care staff described to us was not captured in a clear and easy to follow way in people’s care records. The lack of detailed care instructions in people’s care records meant staff were overly reliant on their knowledge of people’s individual care needs and any changes. This meant people were at increased risk of not consistently receiving the care they needed, particularly when staff didn’t know them well. For example, when they were cared for by newly recruited or agency staff.

People said they felt safe and were well looked after, and relatives agreed. They said they wouldn't hesitate to raise any concerns with senior care staff or the registered manager, and were confident they would be addressed.

People were not fully protected because the quality monitoring systems in place were not always effective. This was because areas for improvement identified through audits and other checks had not been fully addressed, so risks remained.

People received care and support at a time convenient for them because staffing levels were sufficient. The service had a number of staff who were experienced, and knew people really well and how to care for them. Each person had a named keyworker, who was responsible for overseeing the person's care in consultation with them.

Staff had completed safeguarding training and were aware of the signs of potential abuse and knew how to report concerns. People received their medicines on time and in a safe way. The home was clean, fresh smelling and well maintained.

People, relatives and staff thought the home was well led and expressed confidence in the leadership of the registered manager. Staff felt well supported and had good training and development opportunities. Health professionals said staff recognised changes in people’s health care needs and involved them appropriately. The culture of the home was ope

The inspection took place on 23 and 31 May 2016. Our previous inspection in July 2014, found the service to be meeting the regulations inspected of the Health and Social Care Act (2008).

Crelake House is registered with the Care Quality Commission to provide accommodation for up to 27 people who may require personal care. Health care needs are met through community health care services. There were 23 people resident at Crelake House at the time of this inspection.

The previous inspection of Crelake House, July 2014, found that all the standards inspected were met.

The service has a registered manager as they are required to. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People felt safe. Staff had a good understanding of how to report any concerns and protect people from harm and abuse. Measures to manage risk were as least restrictive as possible to protect people’s freedom and uphold their rights.

Medicines were safely managed on people’s behalf.

Staff recruitment practice protected people. Staffing arrangements, training, supervision and support ensured a safe and effective service.

People were treated with respect, dignity, kindness and compassion. Strong relationships had been formed which helped people feel valued and cared for.

People were supported to receive a nutritious diet. People’s health care needs were met by knowledgeable staff who contacted community health care professionals in a timely manner and followed their advice.

People’s care was planned in detail with their involvement and people’s care was centred around their individual wishes and needs, promoting their independence at all times and listening to what they wanted and expected from the service.

Several ways were used to gain people’s views about the service. The registered manager actively looked for ways to provide what mattered to people. A ‘Wishes Tree’ was used to ask people what they wished for, the information from which staff used tried to make people’s wishes come true. A broad range of activities were available to people and staff were open to any achievable way they could improve people’s lives.

Care was only provided with people’s consent and their legal rights were upheld. Staff were relying on community professionals to assess people’s capacity to make decisions. We have made a recommendation about training and systems to promote a more systematic approach to capacity assessment, in line with the Mental Capacity Act 2005 Code of Practice.

There were effective methods in use to assess the quality and safety of the service people received.

We considered our inspection findings to answer questions we always ask:

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well-led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

The service was safe. We looked at three care folders and saw risk assessments had been completed and reviewed. Each folder had a care plan summary and information related to the safety of the person was highlighted in red to make this clear. We saw action had been taken following review of accident forms to reduce the risk of a person falling.

Staff told us there was sufficient equipment to meet the needs of people and the equipment was safe and regularly serviced. One senior care worker said “We have all the equipment we need; it is safe and regularly checked. We are trained and supported in using any new equipment. I would not use any equipment unless I had received training”.

No deprivation of liberty authorisations had been made but the registered manager told us she was aware of the judgement of the Supreme Court, in March 2014, and the guidance provided by the local authority and care quality commission. In response to this the provider was carefully considering the individual needs of people to ensure people were not being deprived of their liberty. Staff told us they received training in the Mental Capacity Act 2005 and deprivation of liberty.

Is the service effective?

We spoke with four people and each told us they were happy with the care they received. Staff we spoke with knew people well and understood people’s care and support needs. We saw comprehensive and detailed care plans had identified people’s needs and how these needs should be met.

One care worker said “I have the necessary training to do what is expected of me. We have regular training, for example training in use of continence pads, catheter care and a fireman came in to talk about fire safety. It is interesting when people come in from outside and you get face to face training”.

One person said “the care is brilliant, very nice. I have been unwell for some time and this is my first time downstairs for a couple of weeks. I came down on the stair lift and staff helped me”. Another person told us “staff encourage you to be independent”.

Staff told us they were kept up to date about people’s care needs. One staff member said “If there is a new person with needs different to what we are used to information about the person’s condition would be researched and information given in the file. Training would be given if this was necessary”.

This showed the service was effective.

Is the service caring?

The service was caring because during our visit we observed staff treating people respectfully and with sensitivity. The atmosphere within the home was positive, light-hearted and relaxed.

We spoke with four people and each told us they were happy with the care they received.

One person told us “It is excellent care. The carers are very good to us they are very caring. They seem to know when people want help we are treated respectfully and maintain dignity in every way; they are very patient. You can have a cup of tea when you want it; there is good food here and you have a choice. It is homely and like a big family; they always make people feel welcome”.

We spoke with a family and a friend visiting people at Crelake House. The friend told us “All is fine, I am very happy with everything. My friend came as an emergency but stayed. We always see the owners around; the new owners have done a good job. All of the carers are lovely”. A family relative said “It’s brilliant, staff are good and friendly they keep us informed”.

Is the service responsive?

The service was responsive because people’s needs were assessed before moving into the home and we saw there were regular reviews of care plans. Staff told us there were processes in place to report any concerns they may have and this could lead to changes in care plans. We saw examples of action being taken in response to learning from incidents that had improved care and reduced risks to people.

Personal profiles had been completed and people’s interests and personal preferences had been recorded. We saw guidance to staff relating to the preferred routines, likes and dislikes people had. This helped them respond to individual needs and wishes.

One person said care was “perfectly adequate. I am treated respectfully I am quite content. Staff explain what is happening; I have not been unhappy about anything. I can join in with activities if I want to but I read and watch television. There is usually a choice of meals but if I don’t like something I can have something different. They are very obliging, no problems, everything is fine, very good”.

Is the service well-led?

The service was well led because staff we spoke with had a consistent understanding of what was expected of them.

The provider undertook an annual survey of people’s views. We saw the results of this posted on the notice board. The owner explained they had a long programme of improvements they planned to make both to the environment and daily routines within the home and this was in addition to things they had already changed.

The registered manager explained changes made within the home meant staff needed more support and regular meetings with seniors and also the full staff team had been planned. Staff told us they got feedback when things were done well and also given information through staff meetings. The most recent meeting was the week before our visit.

One senior care worker gave an example of a positive response from the registered manager to a suggestion for improvement they had made .

Our inspection of 28 November 2013 found that the arrangements for the safe administration of medicines at the home did not protect people using the service to the extent that was possible. The provider wrote to us and told us how medicine management would be made more robust.

When we visited the home on 19 February 2014 we spoke to two people using the service and four staff. We looked at medicine administration records, the record of a staff meeting and visited the medicine storage room.

We found that staff knowledge had been checked and update training in medicines management provided. Medicines management was being closely monitored so that the home's policies and procedures were being followed.

We found that the storage was secure, administration arrangements were improved and medicine records showed that people were better protected from mistakes or mishandling. One person told us that they "did not have to bother" about their medicines which they liked. Another confirmed that their creams and tablets were administered each day as they expected.

The home was handling people's medicines in a safe way and in their best interest and the arrangements were more robust.

We looked closely at some people's care and had conversations with some other people using the service. We spoke to three care workers, two ancillary staff and the provider, registered and deputy managers.

People talked about the friendly atmosphere at the home and how they liked the staff. Their comments included "I can do more or less what I want"; "Excellent. The staff are very good. My room is very comfortable", "There is an odd quiz and some trips out", "I have no concerns about the staff at all" and "I am very happy." Staff told us “The staff are happy and chirpy.”

Nobody received care which they had not consented to and, where necessary, decisions had been made in their best interest. Documentation around this needed improvement.

The standard of care provided was high and people enjoyed a wide variety of activities.

There were arrangements to ensure safe handling of medicines but these had not always been followed which had the potential to lead to errors.

Recruitment was robust so that people were protected and the home had good arrangements to listen to people’s views and protect their health and welfare.

We (the Care Quality Commission) carried out this inspection as part of our scheduled inspection programme.

We talked with six people who lived at the home. They all told us that they were happy with the service provided by Crelake. They told us “I feel safe, I could complain if I wanted to but I have never needed to” and “the staff are all very good and kind”. They told us there was sufficient activity to keep them busy and that the food was of a good standard.

We spoke with five staff who told us that that they felt supported in their role and that they had sufficient training in all areas to help them do their jobs well.

One person told us that prior to living at the home they had visited for half a day to see if they liked it or not. They told us it was the best home they had looked at. We looked at the care provided and records relating to three people. Records relating to people’s care were detailed and personal to each person. The details included risk assessments and care plans and enabled staff to meet people’s individual needs.

People using the service felt there were sufficient staff on duty to meet their needs. They told us “when you ring the bell the always come, even in the night. None of them ever complain about coming to you”.

We saw that all areas of the home were warm, clean and safe for the people living there.

We conducted an unannounced visit to Crelake House on 8 November 2011 spending one hour at the home. We met and spoke with four people who use the service and one person who was a regular visitor. All were complimentary about the care workers with comments including: "They're all very nice" and "Can't fault the staff".

A regular visitor to the home said that they never see any information of a personal nature about people and we saw none when we looked around the home.

Three people who use the service told us that they did not like the television on all the time and they could not hear what was being said anyway. We found that two other lounge areas were, essentially, not available for use. One was not heated and very cold. The second had a hoist, seated weighing scales and a walking frame stored in it. We also found some minor hazards (a loose radiator cover, unlocked cupboard in which was hot water pipes and very hot water at hand basins). At each basin we saw a sign saying that the water was very hot, but as the home admits people with dementia, this can still pose a risk.

We asked people what it was like living at Crelake House and were told:

“Very, very good. Couldn’t wish for anything better.”

“Staff are exceptionally good. They see the little things that make life easier. Friends and family are always made welcome and I look on it as my own home now.”

“It’s not regimented. Very free.”

People who use services told us the staff are kind and know what they are doing. When people need help it arrives promptly. The accommodation is comfortable and people have what they need. People feel safe and would feel confident that any complaint would be listened to and acted upon. People are supported to be independent and are able to do as they please with no restrictions. Food was commented on less favourably. We were told: “Iffy” and “Quite good”.