Croft House Care Home Limited

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider promoted a positive learning culture where staff were encouraged to reflect and improve. Leaders responded to safety events by introducing enhanced learning sessions that shared feedback and set clear objectives. Staff told us these sessions helped them understand how to prevent similar incidents occurring in the future.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Relationships had been built with other health care providers to ensure people had access to the services they needed, this helped to monitor people’s health and wellbeing. For example, the service held a GP round weekly and district nurses attended the service daily. People had healthcare passports which could be created from the new electronic care planning system, ensuring up to date and relevant information was shared with healthcare providers when needed. This also ensured a smooth transition from care home to hospital for people when their health deteriorated.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff demonstrated a good understanding of safeguarding and felt confident raising concerns. Safeguarding alerts were correctly managed and reported to the local authority and CQC. People and relatives told us they felt safe living at the home. Staff were clear about whistleblowing procedures and their responsibility to protect people from harm.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People and relatives were increasingly involved in care planning under the new registered manager, but further work was needed to ensure consistency. Relatives and people told us they were consulted about decisions and risk management. However, some people’s risk assessments lacked clarity around involvement, and not all decisions were recorded in line with best practice.

The provider did not always detect and control potential risks in the care environment in a timely way. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The environment was welcoming and homely, with personalised rooms and communal areas decorated well. However, safety concerns were identified. Fire doors were not compliant with fire and building regulations, such as large gaps around fire doors, which compromised fire safety. This led to enforcement action by West Yorkshire Fire and Rescue which was issued prior to our inspection, and remedial work is scheduled for January 2026. Window restrictors were initially absent in communal areas but installed promptly when identified by the inspection team. Emergency pull cords in bathrooms did not reach the floor and, in some cases, were positioned behind toilets, making them difficult to access in an emergency. Despite these concerns, lounges were clean and well-furnished, and people told us they felt safe and comfortable in the home.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staffing levels were safe, and staff were safely recruited. Training was largely up to date, and staff spoke positively about supervision and support. Some relatives felt weekend staffing could be improved, suggesting a “floater” role for lounge supervision however, rotas showed consistent staffing. Staff members told us consistently there were enough staff and they were not needing to rush.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Infection, prevention and control (IPC) practices were effective. Staff wore personal protective equipment (PPE) appropriately. The whole service was hygienic and clean.

The provider did not always make sure that medicines and treatments were in line with guidelines.

Medication was administered safely but some improvements were needed. While staff demonstrated strong knowledge and people told us they received medicines on time, we found gaps in protocols and governance. Staff did not always know where to go to find information on ‘as and when required’ medicines (PRN), which could lead to inconsistent support to people prescribed these medicines. The registered manager had made progress on significantly reducing the medicine errors at the service. Medicine trolleys were initially cluttered, unsecured, and lacked hand gel, increasing the risk of error and cross-contamination. These issues were addressed promptly after the inspection. Temperature monitoring for medicines storage was, at time, out of range, and staff did not escalate this so action could be taken.