About the service: Crouched Friars Residential Home provides accommodation and personal care for up to 56 older people. Some people also have dementia related needs. The layout of the premises is by means of three interconnected buildings; Crouched Friars [main house], Friars Wing and Colne Lodge [for people living with dementia]. There were 39 people living at the service on the day of our inspection.

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

Rating at last inspection: Inadequate (Published 23 August 2018). The service was placed in special measures.

Why we inspected: This was a planned inspection based on the rating at the last inspection.

We previously inspected Crouched Friars in July 2018 where the service was rated ‘Inadequate’ and placed in special measures. This was because we found that since our inspection in October 2017, where the service was rated ‘Requires Improvement’ there had been a deterioration in the quality of care and people who used the service were at risk of harm. We identified a number of breaches in the regulatory requirements and we took immediate action to protect people. We placed conditions on the provider’s registration to restrict any further admissions to the service and required them to take immediate action to mitigate the risk to people’s safety and welfare.

The provider told us that they had taken action to address the shortfalls we found and made an application to remove the conditions. This application is currently in process.

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.

People’s experience of using this service:

The service had improved, and most parts of the service were safe. The provider and registered manager had a better understanding of their responsibilities for the environment and maintaining health and safety. Repairs had been undertaken and the service was clean.

The registered manager was working with other agencies to improve quality and while significant progress has been made, further work is still needed to imbed the changes and develop the service in line with best practice.

Greater oversight is needed in the management of risks to individuals. There were risks in how staff supported people with moving and handling and the management of catheters.

Medicine management followed professional guidance and significant improvements had been made. Since the last inspection systems had been strengthened to ensure that people received their medicines as prescribed.

People were supported by a consistent team of staff. People told us that staff were available when they needed them. Recruitment of staff was more robust although we have made a recommendation to strengthen the arrangements further.

People told us they were satisfied with the quality and variety of food they were provided with. Meals were nicely presented and looked appetizing.

People told us staff treated them with kindness, dignity and were respectful of their choices.

Care plans were in place but not always up to date and we have made a recommendation about this.

There were a range of activities on offer which people enjoyed and promoted their wellbeing. People were supported to maintain their independence. We have recommended further work be carried out to create a more dementia friendly environment.

People 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 told us that they were able to raise issues, but

Crouched Friars Residential Home provides accommodation and personal care for up to 56 older people. Some people also have dementia related needs. The layout of the premises is by means of three interconnected buildings; Crouched Friars [main house], Friars Wing and Colne Lodge [for people living with dementia]. There were 46 people living at the service on the day of our inspection.

The last comprehensive inspection of this service was undertaken on 12 and 13 October 2017. We identified breaches of the legal requirements and found that people were not sufficiently protected against risks and governance was not effective. After the comprehensive inspection, the registered manager told us that they were addressing the concerns.

We undertook this focussed inspection on 4 and 18 July 2018 to check that they had followed their plan and to confirm that they now met their legal requirements. The inspection was also prompted by information that we received which indicated that safety issues were not being taken seriously and risks were not being mitigated.

The service had a registered manager who had worked at the service for some years. 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.

During this inspection we found that the service did not have effective arrangements in place to identify and manage risks appropriately to support people to stay safe and protect them from harm. The fire detection systems were not working effectively and some areas of the service did not have working detection systems installed. The service was poorly maintained and hazards were created by poor housekeeping and storage. Repairs were not undertaken in a timely way; window restrictors were poorly maintained and did not provide people with adequate levels of protection. The risks of people leaving the service had not been fully risk assessed and effective measures put into place to reduce the risk of harm. Peoples safety was not being protected against the risks associated with unsecured furniture. There was a lack of oversight to identify and manage risks associated legionella, which placed people at risk of harm.

People were not protected from the risk of acquiring infections as the provider did ensure the service was consistently maintained in a clean and hygienic way. We found carpeting heavily stained, and furniture, bedding and bed bases which were not clean. Equipment was not regularly checked to make sure it was clean which placed people at risk of infection. There was an underlying odour of urine in parts of the service including the dining room where people sat to eat their meals.

Individual care plans were in place but these were not always reflective of people’s current needs with steps to guide staff as to how risks should be managed.

Medicine management did not always reflect professional guidance for example there were no plans to guide staff on when they should administer medicines that had been prescribed to be administered on an as required basis. Staff did not always record carried forward medicines which meant that they were not able to effectively audit the amounts of medicines that were in stock.

Recruitment systems for new staff were not robust and did not provide adequate protection to people. There were sufficient numbers of care staff but the shortfalls in cleanliness and hygiene indicated that the housekeeping provision was inadequate.

We found significant shortfalls in the way that the service was led and management oversight and governance did not ensure delivery of quality and safe care. Audits did not identify the shortfalls that we found and so there was no improvement plan in place to evidence planning for improvement of th

At our previous comprehensive inspection to the service on 3 May 2016 one breach of the regulatory requirements was made in relation to Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Whilst improvements were noted since our last inspection in relation to assessing people’s capacity to make day-to-day decisions, other aspects of care provision required improvement.

Crouched Friars Residential Home provides accommodation and personal care for up to 56 older people. Some people also have dementia related needs. The layout of the premises is by means of three interconnected buildings; Crouched Friars [main house], Friars Wing and Colne Lodge [for people living with dementia].

This inspection was completed on 12 and 13 October 2017 and there were 44 people living at the service when we inspected.

A registered manager was in post. 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.

An effective robust system was not in place to assess and monitor the quality of the service.

Quality assurance systems had failed to identify the issues we found during our inspection and to drive improvement.

Not all risks to people were identified and improvements were required to record how these were to be mitigated so as to ensure people’s safety and wellbeing. Improvements were required to ensure that people’s care plan documentation was accessible at all times, reflected all of their care and support needs and how the care was to be delivered by staff.

Although people told us that staff cared for them in a kind and caring manner and whilst some aspects of care by staff was seen to be good, other arrangements were not as effective as they should be and could potentially impact on the delivery of care people received. People were not always actively encouraged to make day-to-day choices and we were not assured that staff always understood the importance of giving people choices and how to support people that could not make decisions and choices for themselves. Improvements were required to ensure the dining experience across the service was consistent.

People’s capacity to make day-to-day decisions had been considered and assessed. Nonetheless, improvements were required to ensure more significant decisions which had been made by staff were in people’s best interests and clearly recorded the rationale for these decisions. Staff member’s understanding and knowledge of the Deprivation of Liberty Safeguards [DoLS] and the key requirements of the Mental Capacity Act (MCA) 2005 required improvement.

Although staff had received regular training opportunities, improvements were needed to ensure the effective delivery of training in line with current legislative requirements and that training provided was embedded in the everyday practice of the staff. Minor corrections were required to ensure staff recruitment practices were in line with regulatory requirements and the provider’s own policies and procedures.

Suitable arrangements were in place to take action when abuse had been alleged or suspected. People were protected from abuse and avoidable harm and people living at the service confirmed they were kept safe and had no concerns about their safety.

Staff described the management team as supportive and approachable. Arrangements were in place for staff to receive formal supervision at regular intervals. Newly employed members of staff received an induction which was suitable for their role and areas of responsibility.

People’s healthcare needs were supported and people had access to a range of healthcare services and professionals as required. Staff had a good relationship with the people they supported. Pe

The unannounced comprehensive inspection of this service took place on the 3 May 2016. Crouched Friars Nursing home provides accommodation and personal care for to up to 56 people. Some people at the service are living with dementia. At the time of the inspection, Crouched Friars was home to 48 people.

A long standing registered manager was place. 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.

This service was rated as Good overall with Requires Improvement in the ‘Effective’ domain.

Relatives told us that the manager and care staff were extremely approachable, available, and willing to listen. People at the service told us that they were very happy with the care they received and their relatives told us the registered manager and staff team were excellent and provided people with the support they needed in a dignified and compassionate way.

The service ensured that staffing levels were adequate and enough staff were employed to meet people’s individual needs. The service had retained a strong core team of staff who knew people at the service well. Staff told us that they enjoyed working at the service. The registered manager increased staffing when people health was deteriorating in health or at the end of their life. The service had safe and robust recruitment procedures.

Staff had received mandatory training and training updates. The registered manager also provided additional training to staff to meet the needs of people at the service.

The service worked collaboratively with health and social care professionals to meet people’s health needs. Qualified nurses managed medicines safely. The deputy manager carried out regular checks of staff competency and medicine audits to ensure that they were being administered correctly.

Care plans, and risk assessments were individualised and updated regularly or when people’s needs changed.

People received freshly prepared meals that considered their individual likes, dislikes and health needs. Relatives were enabled to join their loved ones for meals if they requested to. A variety of hot and cold drinks were available throughout the day if people wanted these.

The service did not always carry out appropriate Mental Capacity Act (MCA) assessments on people and did not apply for Deprivation of Liberty Safeguards (DoLS) when people lacked the capacity to keep themselves safe.

This was a breach of regulation 11 (1) of the Health and Social Care Act. You can see the action we have asked the provider to take at the end of the report.

This inspection took place on 8 December 2014 and was unannounced. Crouched Friars provides care and accommodation for up to 56 older people some of who may be living with dementia

Our previous inspection in May 2014 had identified concerns with the how the service reported outbreaks of infection and how people gave consent to their care and treatment. This inspection found improvements had been made.

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 told us they felt safe living in the service. They told us they were treated with dignity and respect. We saw staff interacting with people in a kind and caring manner. Staff showed a good knowledge of safeguarding procedures and were clear about the actions they would take to protect people.

We saw that the communal areas of the service were clean. However, people’s bathrooms were not clean. This exposed people to an increased risk of infection.

We found that each person had a care plan which detailed their care needs. These were reviewed regularly to ensure they were up to date. People could not always confirm to us that they had been involved with their care planning.

People were supported to have their healthcare needs met. People told us that the service facilitated their access to health care professionals such as their general practitioner, dentist and chiropodist.

People were able to access the local community for personal shopping or social clubs they had attended before moving into the service. Until recently the service had provided activities such as bingo and board games but the activities co-ordinator had left. The registered manager told us they were recruiting a new activities co-ordinator. People told us they were able to access the garden and enjoyed using it in the summer.

The registered manager was visible in the service. Staff received appropriate supervision and training. People and staff told us that the management team were approachable and listened to any concerns.

People told us their needs were met. We saw that people had been actively involved in developing aspects of the service. They were encouraged to have their say about how the quality of the service could be improved. We saw that a system of audits, surveys and reviews were also used to good effect in monitoring performance and managing risks.

As part of this inspection we spoke with ten people who used the service, two relatives, two care staff, kitchen and laundry staff, the deputy manager and the registered manager. We looked at five people's care records and three staff records. Other records we reviewed included staff training and quality and monitoring records. 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?

This is the summary of what we found:

Is the service safe?

Care records were person centred and updated regularly to ensure that people received the care they needed to keep them safe. The service worked with other healthcare professionals to help meet people’s healthcare needs.

We found that the service had not adequately protected people when there had been an outbreak of an infectious disease.

Staff received training to help them carry out their roles safely. We found that annual refresher training for moving and handling was overdue for two members of staff whose records we looked at.

We looked at rotas and found that there were enough trained and experienced staff on duty to meet people’s needs.

We found that the service was aware of its responsibilities under the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (MCA DoLS) and we were assured that nobody was unlawfully deprived of their liberty.

Is the service effective?

People’s health and care needs were assessed in consultation with either the person themselves or their relatives. People’s care plans reflected their healthcare needs and the service worked in conjunction with outside professionals to meet them.

Relatives we spoke with were positive about the service. One relative told us, “We looked at a lot of places for (my relative) and this was the most sensitive to (their) medical needs….The staff are endlessly patient”.

People who used the service told us they were happy with the care provided and spoke positively about the staff. One person told us, “I am satisfied. The staff are excellent and will do anything for me”.

We saw that repositioning charts for a person who was nursed in their bed were fully completed and their risk of developing a pressure sore was reduced.

We found that the service had not been able to provide regular structured activities for several months and people who used the service were not happy with the lack of activities. One person told us, “What can you do if there’s nothing to do?” and another person said, “There used to be activities but not anymore”.

We were concerned that the service did not always ensure it had attained people’s consent before care and treatment were offered. The service was unable to provide any information to show how one person had been involved in the process of moving to a shared room. There was no documentation that assured us that the person had consented to this move. We also found that care plans we looked at had not been signed by the people they concerned or by their legal representative.

Is the service caring?

People were supported by staff who were kind, caring and respectful.

People who used the service told us they were happy and felt well cared for. One person said, “The manager took me to a hospital appointment and waited for me for a really long time. I wake up early and the staff bring me a cup of tea as soon as I am awake. It really is very good here”.

We were concerned that a throwing and catching activity arranged by a member of staff was not appropriate for the people involved and seemed to distress them.

Is the service responsive?

People's care records showed that where concerns about an individual’s wellbeing had been identified, staff had taken appropriate action to ensure that people were provided with the support they needed. This included seeking support and guidance promptly from other healthcare professionals.

People’s preferences and choices had been recorded in their care plans and we observed that care and support was delivered in accordance with people’s wishes. One person told us that the kitchen staff minced their food for them at their request and always offered an alternative if they didn’t like the food.

We pressed the call bell whilst we were speaking with a person who used the service and noted that staff arrived very promptly.

Is the service well led?

The service had an effective quality assurance system in place. We saw that care plans were audited monthly and a system of audits was in place for maintenance of the premises and health and safety.

Staff received regular supervision and an annual appraisal. A system of structured observations was in place to ensure medication was administered correctly.

Although the service had a comprehensive collection of policies and procedures we found that they were generic and were not specific to the service. We also noted that they were not dated and that staff had not had sight of those which were in use.

We were concerned that the manager was unaware of the details of a recent outbreak of diarrhoea and vomiting at the service. We noted that the service had not followed their infection control policy and had not informed the Essex Health Protection Team.

We received information of concern on 3 July 2013 about recruitment of staff and care of people living at the service. At our visit on 18 July 2013 we found that concerns were unsubstantiated and the care provided met people’s needs.

We spoke with four people living at the service and three relatives who were visiting. People told us that staff were helpful and caring, and that there was adequate communication between staff and people living in the service. We found that care was provided according to people's assessed needs.

We spoke with the manager and seven members of staff. We saw that staff had been recruited only after appropriate checks had been made and induction training provided. Medications were administered safely.

People told us that they liked living at Crouched Friars and that staff were supportive and caring. One person said "You can please yourself here, the staff are grand." Another person said, “I love it here.” We found that care was provided according to people's assessed needs and people were asked for their views about how they would like to be cared for. There were effective arrangements to manage medications. Staff were well trained and had the skills required to administer medications safely.

We saw that the premises were suitable and well maintained. The provider had appropriate systems in place to ensure notifications were made to the Care Quality Commission when required.

All the people we spoke with told us that staff were very attentive and knew their needs and care requirements. We spoke with four people who lived in the home. All of them agreed that the care they received was very good. People we spoke with confirmed that they felt their concerns or complaints were listened to and acted upon. They told us they had been involved in decision making about their care from the day of their admission and they felt listened to and supported.

We spoke with one relative who was visiting on the day of our inspection. They told us that they were happy with the care their relative received and confirmed that they felt fully involved in the planning of care.

We found staff were trained to carry out the roles they were employed for. We received positive comments about the staff and the care provided. One person said, “If you want anything you only have to ask and you will get it”. Another told us, “If I wake up early in the morning they will bring you a cup of tea if you ask”. A third person said, "The staff are brilliant. They are always so kind."

During the inspection we identified the provider had not reported any identified abuse, or allegations of abuse in relation to people receiving a service to the Care Quality Commission as required.