Archived: The Croft

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 changed to Requires Improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of the legal regulations relating to relation to safe care and treatment. We found improvements were required about how risks posed to people were managed and mitigated. People were at increased risk of spread of infection and staff were not always prepared for emergencies like a fire. We found improvements were required in the record management and administration of medicines.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were not always supported by staff who had a proactive and positive culture of safety, based on openness and honesty. Lessons learnt were not always embedded into daily work to prevent a re-occurrence, which meant there were inconsistencies in practice. For instance, although staff were provided with information on how to prevent falls. We found falls risk assessments were not always reviewed or updated after a person fell. The provider policies and guidance confirmed it was expected staff would refer falls risk assessments after a person fell.

Systems were in place to cascade learning to staff. Staff completed incident and accident forms. Relatives told us they were informed when their family member had an unexplained injury or had fallen. We found improvements were needed in the recording of conversations with family.

People were supported by staff who worked with healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services.We received positive feedback from relatives about referrals to healthcare professionals. We saw when people were admitted to acute hospitals staff at the home kept in contact with the hospital to arrange a safe discharge.

The local community district nursing team visited the home to provide nursing services to people. They advised us they have a good working relationship with the staff. We received positive feedback from the local GP about how they work with staff to ensure people receive timely and appropriate care.

Systems were in place to ensure information was available for staff to send with people when they were admitted to hospital.

People were not always supported to be protected from potential abuse. Systems were not always effective in protecting people’s right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The local authority confirmed they had investigated safeguarding concerns at The Croft and confirmed people had been subjected to harm. Themes of harm included unexplained bruising, injury or skin damage, unwitnessed falls and medicine errors which had the potential to cause harm. For instance, overdose of medicine.

However, staff had received training on how to protect people from abuse and told us they would not hesitate to raise a concern.

People told us they felt safe. Comments included, “Yes I probably feel safe most of the time, I don’t feel frightened, when an alarm is set off a few times you do wonder what it is” and “I am content, I feel that I am safe, it is clearly the best place for me to be and I have got my telly.” Relatives also told us they felt their family members were safe. Comments included “[family member] is safe,” and “I don’t have to worry about [family member]” and “[family member] is 100% safe living here.”

We observed posters were displayed in the building about how to raise concerns.

People were not always consistently involved in assessing, understanding, and managing the risks to their safety and wellbeing. While staff had completed risk assessments, these were often carried out without meaningful engagement with the individuals affected. This limited people's understanding of the risks identified and did not always reflect their personal preferences, history, or goals.

People were not routinely protected from risk posed to them. We found risk assessments were not updated in a timely manner to ensure staff had up to date information on how to prevent harm to people. One person’s needs had recently changed, staff had been told to use equipment to support the person move positions. However, no risk assessment had been written to advise staff on how to use the equipment safely. We overheard staff asking each other how to use the equipment, this placed the person at a greater risk of harm.

However, people told us they felt risks were managed. Relatives told us they were happy with how staff helped to minimise risk. One relative told us “We have had issues but now they have taken the necessary measures to safeguard her. She tried to go to the toilet, so they brought a commode into her room and that minimises the risk of falls.”

We could not be assured risks to people who were cared for in bed were always mitigated. Records seen did not always show people had been routinely checked by staff to ensure they were safe. This was particularly important for people who were unable to independently summon help.

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

We observed the service was not equipped or suitably prepared in the event of a fire. The care home had recently had a fire alarm activated which the local fire and rescue service had attended. We received mixed feedback from staff who were on duty. One staff member told us they felt the incident was managed well. However, other staff told us it was not managed well.

We found an emergency fire grab bag did not contain a personal emergency evacuation plan for each person, to ensure staff had guidance on how to support them safely in the event of a fire or other event. The list of people had not been kept up to date, which could have an impact on accounting for everyone if the building needed to be evacuated.

Systems were not always effective to ensure equipment was safe to use. For instance, a hoist did not have a working battery when we visited. This caused a delay in one person’s care as staff had to find an alternative battery.

Systems were in place to ensure equipment was serviced in line with national guidelines.

The provider had systems in place to ensure there were enough qualified, skilled and experienced staff to support people. Staff did not always work together well to provide safe care that met people’s individual needs.

People were supported by staff who had been recruited safely. We found pre-employment checks were carried out on all staff prior to a start date being agreed. This included a Disclosure and Barring Service (DBS) check, which provided information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Records showed staff had not always been supported and supervised in line with the provider’s policy, however, staff told us they felt supported. All staff who provided feedback told us they felt their induction prepared them for their role and felt they had opportunities to keep their skills up to date. However, one person told us “Some of the staff do need more training, [family member] says they need more training and that they have been thrown in at the deep end.”

We received mixed feedback from people and their relatives about staffing numbers and deployment. People told us they use their call bell to summon help, “I do use my buzzer but I only press it if it is really necessary.” However, when we were onsite, we observed call bells and alarms going off and staff not responding in a timely manner. We discussed this with the deputy manager who agreed to take action.

Comments from people and relatives suggested they were not happy with the staffing numbers. Comments included, “In the mornings especially, I do think they do need one more to help”,

“I don’t think that there are enough carers…they need more” and “Staff numbers definitely go up and down though, there have been occasions when [family member] has not had her breakfast by 11 o’clock and I have often found her still sitting in her dressing gown.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

We observed people were not offered the opportunity to clean their hands prior to their meal. We discussed this with the manager, who advised that wipes we readily available for staff to support people with hand hygiene. The manager confirmed they would address this issue.

We observed staff did not observe good hand hygiene whilst supporting people with their meals. Staff were observed going from hoisting and changing a bed to supporting people with a lunchtime meal without any hand hygiene between tasks. The concerns we found about infection prevention and control were not highlighted in the provider’s own audits in this area.

We did observe staff wearing personal protective equipment (PPE) when carrying out certain tasks. For instance, aprons when serving food.

People and their relatives told us they thought the environment was kept clean. Comments included “The home is immaculate, the cleaning staff are good, and it is well maintained, they do their best, but the garden could be better maintained” and “Oh yes, her room is spotless even the bathroom.”

People were not routinely supported by staff who consistently followed safe medicine practice.

Medicines, were stored safely and securely. Records relating to the management of medicines needed some improvements, including person centred information in people’s records, to ensure staff had access to all the information needed to them with their medicines.

Most people were prescribed ‘when required’ (PRN) medicines. However, information to support staff to administer these medicines was not always available. When guidance for PRNs was available, it lacked person-centred information, for example signs or symptoms for people who could not express themselves verbally. This meant that there was a risk people would not receive appropriate PRN medicines. When PRN medicines were administered, outcomes of the administration were not always assessed and recorded to ensure they were effective. This was not in line with the provider’s own medicines policy.

Most people were prescribed topical creams. However, sufficient information to support staff administer creams was not always available. Staff did not consistently document where creams had been applied. This was not in line with the provider’s policy and reduced assurance around administration in line with prescriber’s instructions.

Medicines care plans did not always contain additional information for staff to support people with complex conditions such as diabetes. This meant there was a risk that adverse events would not be managed appropriately. The management team was in the process of transferring care plans onto an electronic system, and we saw an example of an updated plan containing the necessary detail.

Regular medicines audits were carried out. However, there was limited evidence that audits were used to drive improvements. Although staff followed the process for reporting medicines-related incidents, a recent increase in these incidents had been identified. There was insufficient assurance that these were thoroughly investigated to identify root causes or used to promote shared learning to support continuous improvement and reduce recurrence.