Crelake House Residential Care Home

Crelake House Residential Care Home (thereafter referred to as Crelake House) is a residential care home that provides personal care for older people. Crelake House is registered to accommodate 27 people, at the time of the inspection 21 people lived at the service.

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

People were protected from the risk of abuse and avoidable harm as staff were aware of their safeguarding responsibilities and knew how to report any concerns.

There were sufficient numbers of staff available to meet people’s needs. Staff had the knowledge and experience to care and support people living at the service. Care records were reflective of people’s individual needs and risks and how these should be managed to reduce the risk of harm. People’s medicines were given as prescribed. Staff followed infection control guidance and had access to Personal Protective Equipment (PPE).

Staff were recruited safely and received an induction and training to ensure they could meet people’s health and care requirements.

Staff understood their roles and responsibilities. Staff liaised with health and social care professionals to ensure people’s health and care needs were met.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Systems were in place to assess and monitor the quality and safety of the care provided. Health and safety checks of the environment and equipment were in place.

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 good. (Published 21 February 2019).

Why we inspected

The inspection was prompted in part by a notification of an incident following which a person using the service sustained a serious injury. This incident is subject to initial inquiries to determine whether to commence a criminal investigation. 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 management of risk of medicines. This inspection examined those risks.

We undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Crelake accommodates people in one adapted building over two floors.

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

This was a targeted inspection that considered infection prevention and control. Based on our inspection of infection prevention and control, we found the service had systems and processes in place to keep people safe.

People told us they were happy with the infection and control measures at the service. Staff always wore PPE (personal protection equipment) appropriately and disposed of it safely. They felt their rooms were kept clean. They could have regular visits and the staff made sure these were completed safely.

We found staff wore masks throughout our visits and the home was clean and odour free. Staff were enabled to put on and take off their PPE safely. Staff training and testing for possible Covid 19 infection was in place in line with the guidance. Checks were completed at regular intervals to ensure staff were putting their training into practice.

People were tested for Covid 19 to ensure they were negative prior to coming to live at the service and, at intervals in line with the guidance afterwards. Visiting family and professionals were also required to have a Covid 19 test and be negative to enter the premises.

Policies, procedures and audits were in place to support good infection prevention and control measures were maintained.

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 Good (published 21 February 2019).

On the 12 January we completed a non-rated, targeted inspection to review the service’s infection prevention and control measures. We judged there to be a breach of Regulation 12 (safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 infection control. We served a Warning Notice on the provider.

Why we inspected

We undertook this targeted inspection to check whether the Warning Notice we previously served in relation to Regulation 12 (safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. The overall rating for the service has not changed following this targeted inspection and remains Good.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

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

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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

We were not assured that Infection Prevention and Control (IPC) practice was safe and the service was compliant with IPC measures. This was communicated at inspection and the registered manager took immediate and appropriate action to address the concerns.

The provider was not doing everything possible to prevent visitors from catching and spreading infections. Staff did not always ensure visitors decontaminated their hands, had their temperature checked or were screened for symptoms of acute respiratory infection prior to entering the service.

Personal protective equipment (PPE) was readily available, however, staff were not always wearing PPE safely and in line with current guidance. We observed staff not always wearing the correct fluid resistant masks, wearing it in the correct way or replacing masks once they came back from a break.

Storage of PPE was not sufficient to prevent the risk of cross contamination.

Arrangements for donning and doffing PPE were not sufficient to prevent the spread of infection and/or cross-contamination. We observed staff removing their PPE in corridors and when they were opening people’s doors after supporting them with personal care.

Arrangements for disposal of used PPE were not sufficient to prevent the spread of infection and/or cross-contamination. Clinical waste bins had been provided but not always used. We found PPE had been discarded in general waste bins throughout the service.

The provider had not ensured that staff were supported to socially distance as much as possible whilst in the service. Staff were receiving daily handovers in a small office where it was impossible to socially distance.

At the time of our inspection the home was closed for all but essential visitors and visits for people who were receiving end of life care. The service had created a safe visiting pod which included a designated entrance and booking system, this would be used when the home could safely allow visitors. Staff used other methods to ensure people continued to have contact with their loved ones such as, video/telephone calls and window visits.

People and staff were monitored closely for any signs or symptoms of Covid-19. People and staff were regularly tested. Staff knew what action they would take in the event any of the test results came back positive for COVID-19.

Systems were in place to respond to an outbreak of COVID-19 infection, to self-isolate individuals who had tested positive for COVID-19 and protect others from the risk of infection spread. A business continuity plan was in place. The service also had an up to date infection prevention and control policy and audits were being conducted.

The service recently experienced an outbreak of COVID-19 among staff and people. The service worked with the local authority infection, prevention and control (IPC) team and other health professionals in managing the outbreak.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified a breach in relation to Infection Prevention Control. Please see the action we have told the provider to take at the end 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 information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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 Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall, or in any of the key questions. Therefore, this service is now out of Special Measures.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

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 the provider and received information that suggested these issues were being addressed. However, when further concerns were raised we brought the planned inspection forward a few weeks.

At this inspection we identified an ongoing breach of regulation in good governance and seven other breaches of regulations. These related to person centred care, consent, safe care and treatment, safeguarding, equipment and premises, staffing, and notification of other incidents. Quality monitoring systems and processes were inadequate to assess, monitor and improve the quality and safety of the service.

Risks for people were not identified, and were not adequately managed in a timely way to reduce them to an acceptable level. For example, people’s risks assessments for two people who had fallen frequently over past few months were not up to date. This meant staff who did not know the person well, such as new and agency staff did not have accurate up to date information about actions needed to minimise those risks.

People’s rights were not upheld because the provider had not acted in accordance with the Mental Capacity Act (2005) and Deprivation of Liberty safeguards (DoLS) for people who lacked capacity. This was an area for improvement identified at two previous inspections, but no improvements had been implemented. Where people were subject to restrictions for their safety and wellbeing, deprivation of liberty applications had not been made to the local authority Deprivation of Liberty Team. This meant some people who lived at the home were at increased risk of being deprived of their liberty unlawfully, which breached their human rights.

Some safeguarding incidents and accidents occurred at the home had not been notified to the Care Quality Commission (CQC). A notification is information about important events which the service is required to send us by law.

People were at increased risk because the service did not follow some of their own policies and procedures. There was a lack of leadership. Clear expectations were not set for staff about their performance. Poor quality monitoring systems meant opportunities to identify breaches of regulations and take corrective action were missed. Staff did not feel valued or that concerns were listened to. Information was provided about the complaints system, but people’s experiences of using it were mixed.

People were supported to access healthcare services. Staff recognised changes in people's health, sought professional advice appropriately. However, poor team communication and record keeping meant advice was not always consistently followed.

People and relatives said staff were caring and compassionate and treated them with dignity and respect. Staff developed positive relationships with people. People’s privacy, dignity and independence was respected. People were able to express their views and were involved in day to day decision making.

Daily routines within the home were task focused, which meant some aspects of people’s care was not personalised to people’s individual choices. The service had recently employed an activity co-ordinator two days a week. However, further improvements in activities were needed, so people were better supported to get out more, pursue their interests and hobbies and reduce isolation. Further improvements in the adaptation, design and decoration of the premises were needed to make them more suited to the needs of people living with dementia.

People received their medicines safely and on time. Improvements in medicines management had been made, with some further improvements needed. A robust recruitment process was in place to ensure people were cared for by suitable staff. People were protected from cross infection because staff followed infection control procedures.

People were cared for by staff that had regular training to gain the knowledge and skills to support their care and treatment needs. Most people reported positively about food. Staff supported people to improve their health through good nutrition and hydration. People who received end of life care at the service were kept comfortable and pain free. We have made three recommendations, about making environment more suitable to needs of people living with dementia, the need to implement staff training and systems to comply with Mental Capacity Act 2005 and about motivating staff and team building.

On 12 June 2018, we identified to the provider and acting manager 10 people that might be at risk of neglect, and asked them to review their care as a matter of urgency. On 13 June 2018 we made a referral to the local authority safeguarding team about those people. We also wrote to the provider highlighting a number of urgent concerns and requesting a response by 15 June 2018 setting out how they were addressing the most serious concerns.

On 15 June 2018 the provider response showed five urgent Deprivation of Liberty Safeguards (DoLS) applications had been submitted to the local authority safeguarding team. They set out plans to implement improved accident/incident reporting systems and improve oversight especially of falls management. They also outlined steps to reduce slip, trip and fall hazards in garden and further work planned to further reduce environmental risks and to address concerns about equipment. In their response, they also undertook to implement a dependency tool to provide assurance that staffing levels were sufficient to meet people’s needs and to improve quality assurance systems immediately.

The provider acknowledged the concerns and said they were committed to making the required improvements. They also undertook a voluntary agreement not to admit any more people to the service until could be assured about safety of people who currently lived there. The service is subject to a whole home safeguarding process.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures.’

Services in speci

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 open, friendly and focused on each person as an individual. People and relatives were consulted and contributed to decisions about their care and the running of the home through individual review meetings and residents’ meetings.

One breach of regulations was identified at this inspection in relation to quality monitoring and care records. We will carry out a full inspection within the next six months to check the improvements needed have been made.

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.

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 .

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.

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 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.