Crofton Lodge

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. This is the first inspection for this newly registered service. This key question has been rated requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care .

The service was in breach of legal regulation in relation to good governance.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy, and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The manager told us, “Our vision centres on wanting to provide quality care and treating people with kindness and respect. We give emotional support, and we involve people in making decisions about their care. We give people choice and make them the centre of what we are doing and ensuring we are providing person centred care. We want to do this in a dignified way.”

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. There was a new management team in post, who led with integrity, openness and honesty. They were aware of issues and priorities within the service and were working towards improvements and changes to systems and processes. This included new digital systems to support the home to be more environmentally sustainable.

The service promoted a positive culture where people felt they could speak up and their voice would be heard. Staff had access to regular supervision and team meetings where they could share their views. Staff were provided with a whistleblowing policy to provide them with information on how to speak up. Staff, however, told us that they did not always feel able to speak up.

The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them. The current provider became the registered provider of this home which had an existing staff team in place. The staff team were not always positive about the provider and the changes they were trying to make. Some staff told us they felt the provider was not responsive, they were discriminated against , did not feel valued and included. We spoke to the provider about this who told us there had been some resistance to some of the improvements they wanted to make, for example, people being supported to go out more. They told us they were committed in ensuring staff had opportunities to speak up and to improving people’s lives.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance, and outcomes. We reviewed provider audits in relation to fire safety which did not detail the concerns we found with the fire doors and the risks of people smoking within the home. The Health and Safety audits did not identify the missing window handles or restrictors.

The Infection Prevention and Control (IPC) audits failed to identify the concerns we found with the unclean bedrooms and out of date, unlabelled and incorrectly stored foods. This audit also failed to identify the cleaning rotas in place were not effective. Therefore, the provider’s audits failed to drive improvement. We spoke to the provider about this, they provided evidence of additional fire compliance training the managers had attended, following our inspection which would aid them when undertaking future fire audits. They also told us, they would ensure they supported the new managers to have the training and knowledge to undertake all other audits. This will need time to become embedded.

The manager was able to confidently tell us how they ensured safe record keeping by following the principles of General Data Protection Regulation (GDPR).

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement. Relatives, staff and the manager shared positive examples with us of collaborative working in partnership. A relative told us how the home supported them by travelling with their relative to a halfway point at the start and end of their holiday visits, due to them living a long distance away from the home.

The service strived to focus on continuous learning, innovation and improvement across the organisation and local system. The service had not always identified where improvement was needed for example, the fire safety concerns, to ensure improvements were made without delay.

Whilst we did identify some shortfalls during this assessment, the provider was responsive to our findings and acted immediately on key areas of improvement. They were passionate about wanting to learn and improve to ensure people were living their best lives. The manager told us, “I am still new to the home so have a lot to work on. Recently we have been working on innovating the culture, we want to have a culture where everyone works together to give people a good life. People need encouragement and prompting and we want to make Crofton Lodge more homely than it used to be.”