Date of Assessment: 23 July to 8 August 2025. We carried out this inspection partly due to concerns about staffing, care provision, the provider’s responses to concerns, and the length of time since the last inspection. We found 3 breaches of the legal regulations at this assessment in relation to governance, consent, risk management and medicines management. Although we found no evidence people had come to harm, there was an ongoing exposure to risk of harm. Although most people and staff felt safe with the care they received, processes were not robust enough to identify all safeguarding concerns. When accidents, incidents or concerns took place, records did not demonstrate lessons were learned to improve care. We received mixed feedback about staffing arrangements and staff skills. Staff received a variety of training, but we were not assured they always demonstrated they understood or retained it. Staff had regular supervision and told us they felt well supported. People were positive about the caring nature of the staff and said they treated them with dignity and respect. Staff spoke about people with genuine warmth. Care records were not always accurate or detailed enough, and did not provide sufficient guidance for staff to support people safely and effectively. The registered managers were considering a different system. Although reviews of people’s care took place and actions were taken if changes were needed, the provider did not always manage concerns or complaints well. The registered managers demonstrated a desire to provide safe and person-centered care to people. They began making improvements at the time of the inspection and told us of their plans to continue with this. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.
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Crescent Office received an overall rating of Requires Improvement at its first inspection under this registration, with four regulatory breaches identified across medicines management, consent/MCA compliance, staffing support, and governance. While staff were caring and recruitment was safe, significant failings in medication recording, staff training, supervision, mental capacity assessment, and quality auditing posed risks to people's safety and wellbeing.
Concerns (10)
criticalMedication management — “Medication administration charts were not used and it was not always clear that people had received their medicines as prescribed.”
criticalStaff training — “None had completed the Mental Capacity Act training, none had completed health and safety training and none had completed dementia care training.”
criticalConsent / capacity — “People with mental health conditions known to affect their capacity had not been assessed for their ability to consent to their care and treatment.”
criticalGovernance — “There were no documented audits undertaken at the service. This meant there was no regular audit of medicines, training, accidents and incidents, or care plans.”
criticalSafeguarding — “We had not received statutory notifications in relation to safeguarding incidents including allegations of abuse.”
moderateSupervision / appraisal — “Two staff members had not had a supervision or appraisal since March 2016 and another had not had any since February 2017.”
moderateIncident learning — “There was no written evidence about what action had been taken in response to the incidents but the registered manager told us they had been investigated.”
moderateCare planning — “Some people had detailed and personalised care plans in place but others were more basic and were largely a list of tasks.”
minorMissed or late visits — “They're supposed to come at 8:15 but sometimes they don't come until 9:30. I've had enough by then, I want to go to bed and I'm waiting and waiting.”
minorEnd-of-life care — “There was no information in any care plans about people's end of life wishes. This meant that staff would have been unable to identify how people wished to be cared for.”
Strengths
· Staff were recruited safely with appropriate DBS checks and references obtained prior to commencement.
· New staff received a structured induction aligned to the Care Certificate, including shadowing experienced staff.
· People were treated with kindness, dignity and respect; staff protected privacy and promoted independence.
· People's diverse needs under the Equality Act 2010 were considered and documented in care plans.
· An on-call system was introduced to cover absences, preventing missed visits.
Quality-Statement breakdown (22)
safe: Medicines managementRequires improvement
safe: Risk assessmentRequires improvement
safe: Staffing levelsRequires improvement
safe: RecruitmentGood
safe: SafeguardingRequires improvement
safe: Infection controlGood
effective: Staff trainingRequires improvement
effective: Supervision and appraisalRequires improvement
Crescent Office improved from 'Requires improvement' to 'Good' across all five key questions, having successfully remediated all prior regulatory breaches relating to medicines management, staff training, MCA compliance, and governance. One minor improvement area remains: end of life care planning needs to be more fully embedded into individual care plans.
Concerns (1)
minorEnd-of-life care — “There was an end of life procedure based on the 'Six Steps' approach to care. This needed to be embedded more fully into care planning to ensure that people had adequate time to consider and plan.”
Strengths
· Provider resolved all previous breaches of regulation since the 2018 'Requires improvement' rating, including medication management, staff training, MCA compliance, and governance.
· Medicines administration record (MAR) sheets introduced and medicines safely managed at time of inspection.
· Staff trained in safeguarding with good working knowledge of signs and symptoms of abuse.
· Comprehensive risk assessments covering environment, mobility, falls, medicines and moving and handling.
· Regular supervision and one-to-one sessions in place for all staff.
Quality-Statement breakdown (24)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staff; Continuous learning and improving careGood