Carr Croft Care Home

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 legal regulations in relation to safe care and treatment and safeguarding.

This service scored 53 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events.

Lessons were not always learnt to continually identify and embed good practice. For example, while accident and incidents had been recorded, these were not analysed for learning and improving. Some people who had fallen did not have their care plans and risk assessments updated in response to their falls to mitigate future risk.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The provider did complete pre-admission assessments; however, these were not always robust or detailed. One person who had recently been admitted to the service was given an incorrect dose of medicine. The provider had not checked with the person’s GP in relation to their medicines as part of their pre-admission assessment which contributed to the medicines error.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The provider did not always share concerns quickly and appropriately. During our assessment we found that some, but not all safeguarding incidents were logged and investigated. For example, we found one person who had unexplained bruising that had not been reported or investigated. The provider had not submitted all required statutory notifications to CQC.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People and relatives, we spoke to told us they were not involved in their care plan and reviewing process. One person said “No, I do not know about a care plan”.

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

For example, fire safety was not always managed well. People’s Personal Emergency Evacuation Plans (PEEP) were not up to date on our first visit which meant staff did not have the correct information to safely support people to evacuate in the event of a fire. No staff member was trained as a fire marshall and the last internal fire risk assessment was completed in 2023. The stairlifts did not have the required safety checks.

Not all people had access to call bells, which meant they could not always summon staff promptly when they needed support. This placed people at risk of harm.

Two rooms had broken door handles and in some parts of the home the painting and décor was not to a good standard. Wardrobes were not secure and one person did not have a radiator cover in their room which placed them at risk of scalding.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

During our assessment, we reviewed staff files and the provider had safe recruitment procedures in place. The training matrix identified some staff members were out of date with their mandatory training.

People and relatives told us they thought staff were busy. Comments included “they [staff] are very busy” and “they seem short staffed”. Staff mainly told us they felt there were enough staff. One staff member said, “sometimes, maybe we need a bit more support”. Inspectors observed that staff were not always available to promptly support people when they were moving without their required equipment.

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.

Effective infection prevention control (IPC) policy processes were in place. The manager was clear on the IPC procedures required and their responsibility to provide personal protective equipment (PPE). During our assessment no concerns were identified with IPC, the home was clean, and staff wore and disposed of PPE correctly.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

The provider had an action plan in place in relation to medicines as recent concerns had been identified with medicines. The provider had completed actions and processes were now in place for the ordering, storage and disposal of medicines. Temperature records showed medicines were stored appropriately. People received their medicines as prescribed.