Background to this inspection
Updated
31 October 2017
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
The inspection was unannounced and was carried out on 21 and 22 August 2017 by one inspector and an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and the improvements they plan to make. We reviewed the information in the PIR, along with other information that we held about the service including previous inspection reports and notifications. A notification is information about important events which the service is required to send us by law.
We spoke with seven people using the service and two relatives of people living at the home. We spoke with seven members of the care staff, a chef, a housekeeper, an administrator, the registered manager, the provider’s support manager and two directors of the provider’s company. We also observed care and support being delivered to people in the communal area of the home. During the inspection, we received feedback from a community mental health professional. Following the inspection, we received feedback from a social care practitioner from the local authority and a community nurse who had regular contact with the home.
We looked at care plans and associated records for seven people using the service, staff duty records and other records related to the running of the service, including staff recruitment and training records, accidents and incidents, policies and procedures and quality assurance records.
Updated
31 October 2017
Croft Manor is a care home that provides accommodation for up to 28 people who require personal care. There were 23 people living at the home when we visited. The home is based on three floors with an interconnecting passenger lift. Most rooms are for single occupation, although there are two double rooms. All rooms have en-suite toilets and washbasins. There are two bathrooms, although only one was being used to bathe people. There are a range of communal spaces where people can socialise and spend time together.
This inspection took place on 21 and 22 August 2017 and was not announced.
There was a registered manager in 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.
At our last inspection, in July 2016, we identified breaches of four regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The care and treatment of people was not always person-centred; people’s capacity to make decisions was not assessed; not all risks to people’s safety had been identified; and quality assurance systems were not effective.
At this inspection, we found some action had been taken, but continuing breaches of regulations were identified.
A quality assurance system was in place, but his had not been effective in identifying and bringing about required improvements. Concerns identified at the last inspection had not been fully addressed, which resulted in continuing breaches of three regulations.
Staff were aware of risks to people’s safety and knew what action to take to keep them safe; however, risk assessments had not always been completed to help ensure the risks were mitigated consistently.
Medicines were administered by trained staff and records showed that most people had received all their medicines as prescribed. However, one medicine was not being given at the correct time and no action was taken when the temperature of the medicines fridge exceeded the recommended level.
Staff sought consent from people before providing care or support. However, people’s capacity to make specific decisions was not always recorded and decisions that staff had taken on behalf of people were not always documented.
While some people told us their needs were fully met, others said this was not always the case. For example, not everyone was supported to have a bath as often as they wished. Following the inspection, the registered manager told us they had introduced new procedures to improve this.
A range of activities was available to people, but no provision had been made for people who did not want to engage in group activities.
People told us they felt safe and staff knew how to identify, prevent and report incidents of abuse. There were enough staff deployed and recruitment procedures helped ensure only suitable staff were employed. Staff received appropriate training and support to enable them to support people effectively.
People praised the quality of the meals and told us there was always a choice. Staff provided appropriate support for people to eat and took action when people lost weight. People were supported to access healthcare services when needed.
People were cared for with kindness and compassion. We observed positive interactions between people and staff. Staff created a calm atmosphere and supported people in a patient and unhurried way.
People’s privacy was protected and their dignity respected. They were encouraged to remain as independent as possible and were involved in planning the care and support they received. They were also encouraged to make choices and decisions about how and where they spent their day.
Staff sought and acted on feedback from people and people knew how to complain about the service. People described an open culture where visitors were always made welcome.
There was a clear management structure in place. Staff were organised, enjoyed working at the home and worked well as a team. They expressed a strong desire to provide high quality care to people.
We identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have taken at the back of the full version of the report.