Crouched Friars Residential Home

Updated 8 October 2022

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 Health and Social Care Act 2008.

Inspection team

One inspector carried out the inspection, shadowed by an employee of the CQC who had recently completed a degree in health and social care.

Service and service type

Crouch Friars is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Crouch Friars is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 15 September 2022 and we carried out a visit to the location’s service on 15 September 2022. We carried out telephone calls to relatives and staff between the 28 and 30 September 2022.

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 (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We reviewed six care plans and risk assessments for people living at the service. We spoke to the registered manager, deputy manager, senior carer, five care assistants, the maintenance person and the housekeeper. We spoke to four people using the service and observed a mealtime on in both parts of the home. We also sought feedback from three health professionals supporting the service and five relatives.

We looked at governance processes in place to monitor the quality of the service provided, including environmental risk assessments, infection prevention and control processes and general quality audits.

Updated 8 October 2022

About the service

Crouched Friars Residential Home provides accommodation and personal care for up to 56 older people, some with dementia related needs. At the time of our inspection, there were 46 people living at the service. The layout of the premises is of three interconnected buildings; Crouched Friars, Friars Wing and Colne Lodge.

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

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.

The registered manager took appropriate action to safeguard people and care staff understood how to raise concerns. Relatives told us they felt their loved ones were safe at the service. Relatives were able to visit the home any time.

The service followed appropriate infection, prevention and control policy and procedure to keep people safe from infection. The registered manager had identified when infection control processes had not always been followed and took immediate action to remedy this.

The service was in a Grade 2 listed building which required constant upkeep to maintain a safe environment. The registered manager was able to show works completed and a continuous schedule of works to continue to keep the environment safe.

People had access to appropriate external health care professional support to manage health needs. Care staff were proactive in seeking guidance when it was needed.

The chef produced quality home cooked food that people enjoyed. Snacks and drinks were available when people wanted them. Peoples nutritional needs were well catered for.

Care staff used handheld recording devices to record all care given. This meant records were constantly updated to give real time view of care and gave good oversight to the management team if people were becoming unwell or needed additional support. These records also held all completed risk assessments and care plans so staff could quickly access instructions to support people well.

People at the end of their life were cared for in a person-centred way. Loved ones were supported during these difficult periods.

The registered and deputy manager had a good oversight of the service and addressed any issues that might reduce the quality of care to people quickly. Relatives told us that they felt able to raise concerns and these would be managed and addressed well.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 23 June 2021). A breach of regulation was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve their governance systems. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

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.

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions safe, effective, responsive and well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Crouched Friars on our website at www.cqc.org.uk.

Follow up

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