The Croft

The Croft is a residential care home providing personal care for a maximum of 6 people in one purpose-built house. The service provides support for people who live with autism and a learning disability. There were 6 people living at The Croft at the time of the inspection.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

People’s experience of using this service and what we found

Right Support:

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People were supported in a way which mitigated risks to their safety and welfare. They received their medicines safely and in the ways they preferred.

There were enough, safely recruited, staff available to meet people's needs.

There were systems in place to minimise the risk of infection and to learn lessons from accidents and incidents.

Right Care:

Support was person-centred and promoted people’s dignity, privacy and human rights.

People had access to appropriate healthcare services and nutrition to support their health and well-being.

Staff were supported to develop the skills and knowledge they needed to support people effectively.

Right Culture:

The ethos, values, attitudes and behaviours of leaders and staff ensured people who lived at The Croft led confident, inclusive and empowered lives.

There was a culture of continuous learning and development within the service which enabled people to experience meaningful lifestyles.

Systems were in place to monitor the quality of the support and services provided for people and address any shortfalls in a timely way.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 9 March 2022) and there was a continued breach of regulations. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out a focused inspection of this service on 11 January 2022. A continued breach of legal requirements was found. The provider completed an action plan to show what they would do and by when to improve governance.

We undertook this comprehensive inspection to check they had followed their action plan and to confirm they now met legal requirements. The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Croft on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The Croft is a residential care home providing personal care for up to a maximum of six people who live with a learning disability and associated needs. There were five people living at The Croft at the time of the inspection.

People’s experience of using this service and what we found

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

Based on our review of the safe and well-led key questions the provider was able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture. For example, support was person-centred and focused on developing people’s life experiences in a safe way. There was a positive culture amongst staff that was inclusive, and people were supported to maintain relationships.

Day to day leadership and oversight within The Croft had been effective in identifying and addressing shortfalls. However, the provider’s wider governance systems continued to be ineffective at responding to and resolving identified issues in a timely manner.

People were supported by staff who were trained and understood how to help them stay safe.

There were enough staff to meet people’s assessed needs and medicines were administered safely.

We were assured measures were in place to prevent the spread of infection to both people and staff.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published 11 February 2021) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of three regulations. The provider remains in breach of one regulation.

This service has been in Special Measures since 11 February 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We carried out an unannounced inspection of this service on 19 October 2020. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions safe and well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Croft on our website at www.cqc.org.uk.

Enforcement

We have identified a continuing breach in relation to the provider’s monitoring and improvement of the quality of the service at this inspection.

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The Croft is a residential care home providing personal care for up to a maximum of six people with learning disabilities and autistic spectrum disorder in one purpose-built building. There were six people living at The Croft at the time of the inspection.

People’s experience of using this service and what we found

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the guidance CQC follows to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The Croft was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture. For example, some people were not supported to access planned activity within their local community. This impacted on people’s ability to develop and maintain their social skills.

Infection control procedures had not been managed safely. Personal protective equipment (PPE) had not been used in line with government guidance and a suitable area had not been identified for staff to put on, take off or dispose of PPE. A lack of housekeeping staff impacted on the provider’s ability to ensure deep cleaning of the premises was regularly carried out.

People were at increased risk of infection as environmental risks had not been suitably and sufficiently assessed or communicated to staff.

Some people’s assessed care needs had not always been met due to a continued shortfall in the amount of staff deployed within The Croft.

Leadership and oversight within The Croft had not been effective in identifying and addressing shortfalls. In addition, improvements that had previously been made had not been sustained.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

The last rating for this service was requires improvement (published 13 December 2019) and there was a breach of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection not enough improvement had been sustained and the provider was still in breach of regulations.

Why we inspected

We received concerns in relation to the management of infection control, staffing and governance arrangements. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to inadequate. This is based on the findings at this inspection.

Enforcement:

At this inspection we have identified breaches of regulations in relation to people’s safe care and treatment, infection control practice, staffing levels, maintenance of the premises and the provider's governance systems.

For each of these breaches you can see what action we have asked the provider to take at the end the full version of this report.

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The Croft is a residential care home providing personal care to up to a maximum of six people with learning disabilities or autistic spectrum disorder. There were six people using the service at the time of the inspection.

The Croft provides accommodation in one purpose-built building. The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service should receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

The Secretary of State has asked the Care Quality Commission (CQC) to conduct a thematic review and to make recommendations about the use of restrictive interventions in settings that provide care for people with or who might have mental health problems, learning disabilities and/or autism. Thematic reviews look in-depth at specific issues concerning quality of care across the health and social care sectors. They expand our understanding of both good and poor practice and of the potential drivers of improvement.

As part of thematic review, we carried out a survey with the unit manager at this inspection. This considered whether the service used any restrictive intervention practices (restraint, seclusion and segregation) when supporting people. The service used some restrictive intervention practices as a last resort, in a person-centred way, in line with positive behaviour support principles.

People’s experience of using this service and what we found

There were occasions when the provider didn’t ensure sufficient numbers of suitable staff were deployed. People did not always receive one-to-one support if staff were absent and often didn't have two-to-one staff to enable them to go out. This was a breach of the regulation on staffing.

While quality assurance systems and delivery of the service had improved in many areas, there was still unidentified shortfalls with monitoring staff deployment, risks and some record keeping.

People weren’t always protected from risks or had their positive behaviour support plans implemented when staffing was insufficient. People were not encouraged and assisted to maintain their privacy and dignity as well as they should have been.

We made recommendations about identifying shortfalls, ensuring staff practice and vigilance improves to reduce people's risks and maintain people's dignity.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies supported this practice. However, some staff practice in recording best interest decisions was ineffective and required improvement.

The service didn’t apply the full range of the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence. The outcomes for people did not fully reflect the principles and values of Registering the Right Support for the following reasons [lack of choice]. For example, people could not choose when they wanted to go out because there were insufficient staff to provide the two-to-one support they needed.

The culture of the service did not always achieve good outcomes for people. It was person-centred and open, but staff enabled people to express too much freedom and offered insufficient guidance for them to experience a normal lifestyle. Boundaries for behaviour had blurred.

However, safeguarding systems were followed. Medicine safety and infection control and prevention were well managed. The premises were maintained. Staff learnt lessons when incidents arose.

People's needs were effectively met in other areas, for example, with health, nutrition and personal care. Their environment was sparse but suitable to their needs. Staff worked consistently well with other healthcare professionals. People's equality, diversity and independence were respected. They were supported by caring and compassionate staff.

People's communication needs were met. Concerns raised about the service were satisfactorily addressed. People were assured a good end of life experience when the time came.

Staff were clear about their roles and partnership working with other organisations was effective.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 22 August 2018). The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Croft on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

There was a registered manager in post. 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. In this report when we speak about both the company we refer to them as being, ‘the registered persons’. At the last inspection the service was rated, ‘Good’. At the present inspection the service deteriorated to ‘Requires improvement’.

The quality assurance systems in place were not effective as they did not always identify where improvements were required or lead to the action required to ensure good quality care. For example, the provider had not ensured that there was sufficient staff on duty.

Medicines were managed safely. Where people were unable to make decisions for themselves arrangements had been made to ensure decisions were made in people's best interests.

People received person-centred care. There were systems, processes and practices to safeguard people from situations in which they may experience abuse including financial mistreatment. Risks to people’s safety had been assessed, monitored and managed so they were supported to stay safe while their freedom was respected. Background checks had been completed before new staff had been appointed.

There were arrangements to prevent and control infections and lessons had been learned when things had gone wrong.

Staff had been supported to deliver care in line with current best practice guidance. People were helped to eat and drink enough to maintain a balanced diet. People had access to healthcare services so that they received on-going healthcare support.

People were supported to have maximum choice and control of their lives and to maintain their independence. Staff supported them in the least restrictive ways possible and the policies and systems in place supported this practice.

People were treated with kindness, respect and compassion and they were given emotional support when needed. They had also been supported to express their views and be involved in making decisions about their care as far as possible. There was a positive culture in the service that was focused upon achieving good outcomes for people. People had been supported to access activities. People had access to lay advocates if necessary. Confidential information was stored securely.

Information was provided to people in an accessible manner.

The registered manager recognised the importance of promoting equality and diversity.

The provider had taken steps to enable the service to meet regulatory requirements. The provider had put in place arrangements across their services to involve people, in the running of the service. There were arrangements in place that were designed to enable the service to learn and innovate and for working in partnership with other agencies to support the development of joined-up care. People’s concerns and complaints were listened and responded to in order to improve the quality of care.

Further information is in the detailed findings below.

We found the accommodation did not provide a dignified setting and people were not always supported to access the community on a regular basis. We found this had a minor impact on people.

We found there were not enough qualified, skilled and experienced staff to meet people's needs. We found this had a moderate impact on people.

We found the provider did not have effective systems to regularly assess and monitor the quality of the service people received.

Before we visited the home this time we saw the provider's action plans, which showed how they were going to address the issues.

Two inspectors carried out this inspection. We found that improvements had been made in regard to all of the issues we highlighted at our last inspection and in line with the provider's action plan.

During this visit we observed how the five people who lived in the home were cared for. This was because some people had different ways of communicating and could not tell us directly about their experiences of the care they received.

We looked at two care plans in detail. We spoke with the provider's operational manager, the manager of the home, the deputy manager and two members of staff. We also spoke with a relative and a healthcare professional.

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people told us.

Improvements to staffing levels and the numbers of staff who could drive the provider's vehicle, meant people were able to engage in more community based activities. People's activity plans were based on what people liked to do and what the person would accept given their complex needs within the autistic spectrum.

The provider had commenced a programme of refurbishment and enhancement for the environment which was on-going and carried out at a pace which was suitable for the people living in the home. The environment and furniture remained at a functional level to meet people's needs but had been enhanced. For example, art work had been applied to walls.

The provider had reviewed arrangements for the recruitment of new staff. This meant that new staff were able to start work in the home in a more timely way. Because they had done this, and improved the way they monitor staffing levels, they were able to consistently provide the correct numbers of staff to meet people's support needs.

The provider had reviewed the way they assessed and monitored the quality of service people received. We found they had developed a new system for recording audits which included action plans for identified shortfalls. We also found the provider was reviewing the way they gathered people's views as written questionnaire's did not always meet people's communication needs.

We considered our inspection's findings to answer questions we always ask: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? This is a summary of what we found:

Is the service caring?

All of the people who used the service had complex needs for support. They used a combination of words, sounds and gestures to communicate. People said and showed us by their relaxed manner that they considered staff to be caring and attentive. We observed staff speaking to people in a courteous and polite way. However, the accommodation was unnecessarily bare and did not provide a homely and inviting space in which to live.

Is the service responsive?

We saw that people's individual needs for support and healthcare had been assessed and met. Staff knew about each person's individual support needs, choices and preferred routines. People received the support they needed to do personal and household tasks. However, both of the parents and three of the care managers we spoke to thought that people were not being sufficiently supported to be involved in social and occupational activities and to access the community.

Is the service safe?

Staff understood their roles and responsibilities to ensure that people were protected from the risk of abuse. People were protected against the use of unlawful or excessive control or restraint because the provider had made suitable arrangements. There were policies and procedures to guide staff in the correct application of Mental Capacity Act and Deprivation of Liberty Safeguards. These measures are designed to protect people who are unable to make decisions for themselves. We found when people lacked capacity their best interests had been considered

Is the service effective?

The provider had not employed enough staff and had not ensured there were sufficient staff on duty to enable people to always receive the individual attention they needed. In addition, the support some people received had not been reviewed and evaluated as frequently as necessary. Furthermore, some people had not been supported to develop personal goals to enable them to pursue their interests and acquire new skills. These shortfalls had increased the likelihood that people would not receive all of the support they needed and wanted.

Is the service well led?

The manager had been in post for approximately two months. We noted that the provider had started an application process for him to be registered with us. The law says that the provider is required to have a registered manager. This is because we need to establish that there is someone in charge who has the knowledge and skills necessary to ensure that the service is caring and meets people's support needs.

There was a clear line of management. This meant that important decisions about organising people's support were made by managers while support workers could use their own judgement to provide a flexible service. However, other aspects of the management arrangements were not robust. The system used to consult with stakeholders about the development of the service was not wholly effective. This was because some of the information was inaccessible and there was no clear system to implement suggested improvements.

Some quality checks had been completed to ensure that important measures such as the management of medication, fire safety and infection control were in place. However, other required checks had not been completed at all. In addition, some of the quality checks that had been completed were of limited value. This was because when problems had been identified effective and timely action had not been taken to address the shortfalls. These problems reduced the provider's ability to ensure that people reliably received the support they needed in a safe setting.

Before we undertook our visit we reviewed all of the information we had about the service. During our visit we observed the support people received and spoke with one person, staff and a visiting professional Deprivation of Liberty Safeguards (DoLS) assessor. We also looked at a range of records kept in the home.

We observed people were supported in a respectful and dignified way. Staff were responsive to each person's way of communicating their needs, wishes and choices.

One person told us how they looked forward to going out for a day trip with staff to Rutland Water. The person said, 'I am going to a caf' and will have a fry up breakfast.'

Staff had been given training and support that helped them to understand peoples' complex needs. Staff told us this helped them feel confident in carrying out their roles.

The statement of purpose reflected the current service provision and there was a procedure and policy in place to respond to any concerns or complaints received. Overall we found the service was well led and the manager and home owner regularly checked and monitored the services provided.