Crossways Nursing Home

Incidents and accidents were reported; however, documentation to show how lessons learned were shared with staff was not always in place. Some incident forms contained contradictory information, contained minimal information and some key information was not recorded. Potential risks to people’s health and welfare had been assessed and reviewed regularly. Some information in care plans was not always consistent and some areas of detailed guidance was not always included in people’s care and support plans. The environment was visibly clean but not always well maintained. There was a maintenance plan in place, but this lacked clarity regarding what actions had been completed and who was responsible. Some shortfalls were identified regarding the recruitment process for some new members of staff because employment histories were not always fully complete. Shortfalls were identified in the management of medicines; these included poor record keeping and topical creams and lotions not always having their opened date recorded. The medicine audit had not identified the shortfalls highlighted during our assessment. There were enough staff to meet the needs of people and staff knew how to support people safely, as individuals. Staff followed safeguarding processes. Processes were in place to manage safeguarding concerns. People told us they felt well supported by staff.

We identified a breach of regulation in relation to good governance. The provider’s systems had not consistently been used to identify shortfalls and drive improvement in the service. Communication systems were not always robust because records of staff meetings for example, were not always detailed and no actions were recorded. Documentation of some records was of an inconsistent quality. There was limited information about how learning was shared with staff.

Staff told us there was an open culture and they felt valued and respected. They spoke positively about the registered manager and told us they felt listened to. Relatives told us they found the registered manager to be approachable and caring.