Culrose Residential Home

Updated 27 September 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by one inspector. An Expert by Experience made telephone calls to people and their relatives to ask about their experience of the service.

An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Culrose Residential Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with 5 relatives of people who used the service and 2 people who used the service. We spoke with 11 staff members including the registered manager and care staff. We reviewed 13 care records and 2 recruitment files. Multiple records relating to the quality, safety and monitoring of the service were reviewed.

Updated 27 September 2023

About the service

Culrose Residential Home is a care home providing personal and nursing care to 26 older people at the time of inspection. The service can support up to 32 people.

People’s experience of using this service and what we found

The service had failed to ensure that all moving and handling equipment was serviced in line with Lifting Operations and Lifting Equipment regulations 1998 (LOLER) regulations in order to ensure its safety and suitability.

Risks to people were not adequately planned for, managed or mitigated. Some care plans contained conflicting information, making it difficult to ascertain what care people required to keep them safe. The majority of the care plans we reviewed did not contain sufficient detail about the care people required to keep them safe.

Where people had distressed behaviours, there was not always sufficient information in care planning with regard to how people could be positively supported to avoid, reduce or deescalate the situation. Some people with complex mental health conditions which could impact their well being did not have care plans for these.

The service did not always identify signs of potential abuse such as unexplained bruising and investigate these to ensure people were safe.

The staffing level or the deployment of staff was not always sufficient to enable staff to respond to people’s requests for support in a timely manner or for staff to respond to alert equipment such as pressure mats to reduce the risk of falls.

There was a high number of falls in the service. Whilst the manager had identified this, they had not identified the shortfalls we found in staff responding to call bells and alerts in a timely manner. This created a risk of people having falls and could also have contributed to the number of falls.

The service was not consistently clean throughout. Some items could not be cleaned effectively as the surface was broken or damaged. This increased the risk of the transmission of infection.

The service was not decorated and adapted in line with dementia friendly guidance. The environment was poorly maintained in the older parts of the building and this did not uphold the dignity and respect of people using the service.

Medicines were managed, monitored and administered safely. Recruitment procedures were safe.

The service was found to be in breach of eight regulations under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The quality assurance system did not appropriately identify the issues we found at inspection. Therefore, this was ineffective. The service had deteriorated in compliance with the regulations since the previous inspection.

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

Rating at last inspection

The last rating for this service was ‘requires improvement’ (published 19 September 2019).

Why we inspected

The inspection was prompted in part by notification of an incident following which a person using the service sustained a serious injury. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the safety of equipment. This inspection examined those risks.

You can see what action we have asked the provider to take at the end of this full report.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.