Croham Place

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.

This is the first assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 incidents. Lessons were learnt to continually identify and embed good practice.

The provider learned from mistakes and took action to improve people's safety. The registered manager reviewed accidents and incidents records. Analysis of the records helped the provider identify where improvements were needed and we saw evidence that improvements were made where necessary.

Reviews of people's care included referrals to appropriate healthcare professionals. Where a person’s needs has changed and issues arose, appropriate action was taken to reduce the risk of reoccurrence. This evidenced the service learnt from incidents that arose.

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.

Healthcare professionals told us that engagement with the provider was good. One healthcare professional we spoke with told us, “I have good communication with the team on an ongoing basis and this helps in meeting the needs of people more effectively and speedily”. We saw procedures were effective and people’s health benefitted from good working and co-ordinated relationships with healthcare professionals.

People’s relatives said their family members felt safe at Croham Place and they were well supported by staff. Comments from relatives included, "The staff are supportive of people in the home. It [the home] is always well kept, clean and fresh”, “People are kept safe” and "I don't have any worries, I am pleased with the care my [family member] receives, it’s a weight off my mind to know they are safe."

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.

People were protected from abuse and improper treatment. The service had appropriate safeguarding procedures in place and staff received on-going training around identifying signs of abuse and the actions they should take. Staff understood their role in protecting people from abuse and their duty to report any suspicions of abuse. Where safeguarding concerns were raised the provider acted promptly and decisively to protect people. This included making safeguarding referrals to the local authority, notifying CQC and taking action to ensure people’s safety.

People can only be deprived of their liberty with appropriate legal authority. In a care home this is done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found the provider kept up to date and accurate records and was working within the principles of the MCA.

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

People were protected from avoidable harm or danger because risks for each person were identified and managed. Care records contained risk assessments about each person which identified measures taken to reduce risks as much as possible. These included risk assessments associated with people's nutritional needs, hydration, moving and handling, pressure sores and falls. People identified as being at an increased risk of skin damage had pressure relieving equipment in place to protect them from developing sores. This included pressure relieving mattresses on their beds and cushions in their chairs.

The provider had effective process in place, such as risk assessments and quality assurance audits, which helped to detect and control identified risks in the home. They made sure equipment and facilities were well maintained and refreshed where necessary and new technology supported the delivery of safe care.

People said they were happy with their accommodation. They said they felt safe and they liked their bedrooms which we saw were clean and tidy and safe for people. The home was uncluttered and safe for people.

An auditing procedure was carried out by senior staff on a regular basis in areas such as health and safety, the home environment, medicines management, care plans and staff records. The registered manager said part of the system required action plans to be developed to address where any issues or concerns were identified. This assisted in preventing issues from arising again and it ensured they were addressed.

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.

People indicated they felt well supported by staff. Relatives told us they visited their family members regularly and often without notice. They said there were always enough staff on duty when they visited. Comments from relatives included, “There are always enough staff on duty when I visit.” And “I visit regularly, I try to visit once a week and there are always good staffing levels whenever I go there.” And “My [family member] is well cared for by kind and compassionate staff.” We saw there were sufficient numbers of staff on duty for each shift to meet people’s needs when we visited the home.

Staff told us they received support through supervision. This included one to one meetings and team meetings. The registered manager showed us information that set out regular individual supervision meetings for individual staff members. This was recently introduced together with a new supervision format. This set out the agenda for supervision meetings and included the direct work staff undertook with people. These measures helped to ensure staff have the skills, knowledge and experience to deliver effective care and support.

Staff told us they received training in core areas such as first aid, infection control, the Mental Capacity Act, safeguarding, food hygiene and equality and diversity. Training programmes also included training on working with people who had dementia, people whose behaviours resulted from anxiety and distress, tissue viability and pressure sores and the administration of medicines.

The provider’s recruitment practices were followed to help make sure that all staff were suitable for their roles in the home. The process included carrying out interviews, criminal records checks, proof of identity and taking up two references. This meant people were supported by staff whom the provider assessed to be safe to deliver care and support.

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.

The home had effective infection control policies and procedures in place that were in line with best practice guidance. Senior staff carried out regular audits of infection control practices. We reviewed recent audits and saw they were comprehensive and where issues were identified they were addressed appropriately and action taken to reduce the likelihood of reoccurrence. Staff we spoke with knew the relevant policies and were able to describe how they ensured the risks of infections spreading were properly controlled.

Staff wore appropriate and personal protection equipment (PPE). The housekeeping staff used a cleaning schedule to ensure all areas of the home were kept clean.

Staff received food hygiene training and we saw food preparation was undertaken hygienically.

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.

People's medicines were managed so they received them safely. We found there were appropriate arrangements in place in relation to obtaining, storing, administering and the recording of medicines which helped to ensure they were given to people safely. Staff regularly checked stocks of medicines at the home to ensure these were correct and people had received their medicines as prescribed. Accurate medicines administration records (MAR) were maintained.

Staff completed safe medicines management training and regular competency checks were undertaken to ensure staff adhered to safe medicines management practices.

People's records contained information about their prescribed medicines and how they should be supported with taking their prescribed medicines. There was also detailed guidance for staff about giving people 'when required' medicines, which included personalised information about why, when and how a person should be given ‘when required’ medicine.