The Croft

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 service since a change of provider in October 2025. This key question has been rated 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 a legal regulation in relation to people’s safe care and treatment, in respect of how risks were managed and the how people’s medicines were managed.

This service scored 50 (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. Staff listened to concerns about safety and investigated and reported safety events. However, individual people’s care plans were not always updated to reflect changes in their needs or highlight risks posed to them. Opportunities for sharing learning when things went wrong were taken. Lessons learnt were shared across the organisation.

Staff told us they knew how to report incidents and accidents. However, we found there was a lack of action after falls to ensure records were reviewed and updated if needed.

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.

People who had been admitted to hospital were supported to return home. Staff maintained good communication with external bodies when people were away from their home.

People were referred to external healthcare professionals when needed, for instance, dietitian, and speech and language therapists. Where people needed support to attend external medical appointments, staff supported this and helped to arrange transport.
 

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 and their relatives told us they felt safe. Comments included, “I do feel safe” and “[Person] is not neglected, yes [they] are safe”.

The provider had a safeguarding policy in place, which followed best practice guidance. Systems were in place to identify, report and manage safeguarding concerns. The manager had worked with the local authority to investigate recent neglect concerns. Staff had received training and told us they were aware of their responsibilities.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The provider was aware of their responsibilities to apply to the supervisory body (local authority) when a person was not able to consent to live at The Croft and were not safe and free to leave. There were systems in place to monitor applications made.

The provider did not work well with people to understand and manage risks. People were placed at risk of harm due to the lack of effective and robust risk management.

We found the provider failed to ensure risks posed to people and staff were fully assessed and mitigated. This placed people at risk of avoidable harm. For example, fall risk assessments were in place, these did not fully explore how a person should be supported or what staff should do to prevent a fall. People’s risk assessments were not reviewed and updated to reflect individuals' current needs and risks after a fall. Some people who required support with moving positions did not have any risk assessments in place, to ensure staff were aware of what equipment to use and when. The provider told us, every person at The Croft should have a moving and positioning risk assessment in place, we found this was not the case. In addition, not all people who used equipment to help them maintain their safety in bed had risk assessments in place to advise staff on how to prevent harm. For example, 1 person used bed rails to keep them safe in bed and no risk assessment was in place.

People who were at risk of pressure damage were placed at greater risk of a deterioration in their skin health. People’s risk assessments did not always detail how staff should support them. In addition, records did not always demonstrate people had not been supported with pressure relief as described in care plans. For instance, 1 person’s care record stated they needed 4 hourly repositioning, however, daily notes did not show this had happened. We could not be confident the person had the support they needed.

We found the provider had failed to identify risks to the health and safety of people and do all that was reasonably practicable to mitigate any such risk to prevent or reduce avoidable harm.However, following feedback, the provider introduced a care plan and risk assessment tracker with monthly oversight to support completion and review of risk assessments.

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

Remedial work had been identified for fire doors in November 2025, however, we observed the same issues were noted in March 2026. We found delays in remedial work being carried out which had the potential to put people at increased risk of harm. We acknowledge The Croft’s new provider was working with their landlord to improve the environment where people lived. This had been ongoing since October 2025. One unit at The Croft remained closed due to refurbishment work.

The Croft had been inspected by Food Standard Agency on 7 October 2025, the inspection identified some concerns. We had ongoing concerns about the main kitchen and made a referral to the local Food Standard Agency team. The Food Standards Agency agreed to revisit The Croft and reported ongoing concerns following their visit. The new rating will be displayed in due course.

The manager advised us staff had not conducted a simulated fire evacuation since the new provider had been in place. We noted weekly fire alarm testing was carried out. However, fire drills were not regular. This placed an increased risk to people in the event of a fire. For instance, records showed no fire drills had been carried out from February 2026 to June 2026.We asked the provider to ensure all staff received an opportunity to practice a fire drill. We received confirmation this had been completed.

Systems were in place to ensure equipment was serviced in line with national guidelines. A manager daily ‘walk around’ did highlight some environmental concerns, for instance, a broken dishwasher. However, records shared with us did not always demonstrate the concerns were resolved in a timely manner.
 

The provider did not always make sure there were enough qualified, skilled and experienced staff. However, staff worked together well to provide safe care that met people’s individual needs.

People and their relatives told us consistently they felt there were not enough staff deployed to support them and maintain their safety and dignity. We received significant concerns from people and their relatives about staffing levels. We also observed delays in people receiving support in a timely manner. Comments from people included, “I am cared for well but this company are dreadful, they have cut back on the staff, they are mean, I press the buzzer and staff say sorry you will have to wait 15-20 minutes”, “I feel safe but [there is] not enough staff. [It has] not been very good here, especially in the mornings, they need an extra staff” and, “I have been on several respites [short term stays] here, it is ok, but there is not enough staff, staff are over stretched all the time.” People also told us they had gone looking for staff when other people had fallen or were in need of support. People told us this had distressed them.

Relatives also told us they had concerns about staffing levels. One relative told us, “It is erratic, there is not always adequate [levels of] staff, [person] is immobile and needs 2 carers. Occasionally [they] have been left as 2 [staff] are not available and [they] have soiled themselves. That is not acceptable.” Another relative told us sometimes “staff are over stretched and stressed, [person] is not up [supported out of bed and ready for the day] at a reasonable time as there are no staff available, [person] is bedroom bound.

People and relatives told us they were concerned about staffing levels over weekends. Comments included, “Always problems with the homes phones, staff are busy or we can’t get through to [relative], getting through on weekends is far more difficult to get them[staff] to answer the phone, it happens more often than not”, “Yesterday Sunday was awful” [not enough staff] and “Staffing has gotten smaller and they [staff] have got a lot to do.” We discussed our concerns with the provider. They recognised the need to further improve staff deployment and oversight arrangements to promote a more consistent experience for people. Recruitment to key posts was underway to support activities, engagement and service improvement.

People were supported by staff who had been recruited with robust recruitment processes. Staff recruitment files contained full and robust checks as required, including a Disclosure and Barring Service check (DBS). A DBS checks for criminal convictions and inclusion on lists of people who would be unsuitable to work with people at risk. Systems were in place to support staff, with 1-1 meetings with a line manager and an annual review of their performance. However, where staff had declared health conditions, records did not clearly show how and what support they needed to support them in their role.

Systems were in place to ensure staff had the right skills and had opportunities to attend training and had their competency assessed.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

On the first day of our assessment, we observed people were not offered the opportunity to clean their hands prior to their meal. We discussed this with the manager and noted improvements on the second day we visited.

Staff were observed to be wearing nail coverings which was not in line with good hand hygiene or the provider’s policy. This had not been picked up by the manager in any audits.
We observed poor hand hygiene when staff were administering medicines to people.

Some areas of the home were unclean and poorly maintained including a toilet in the lobby/reception area. We saw it was in need of cleaning on our first visit and it remained in the same condition when we visited 3 days later on our second visit. We asked the provider to ensure it was cleaned prior to us leaving which it was. Other areas of the home which required cleaning were the main medicine room and kitchenettes in each unit.

We found food items were poorly stored in the kitchenettes, and some food items had not been labelled to ensure they were still safe to use following opening. Kitchen cupboards were broken and in a poor state of repair which increased the risk of infection.

Some of the environmental issues we found formed part of a wider refurbishment programme already underway. The service had systems in place to monitor infection prevention and control and had not experienced any recent infection outbreaks.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were placed at greater risk of harm due to the lack of effective risk management for high-risk medicines.

People who were prescribed emollients or other flammable medicines did not have care plans and risk assessments in place to alert staff on how to prevent harm due to fire or burning.

People were prescribed medicines for as needed use (PRN medicines). We found PRN protocols were not always in place. Where they were in place, protocols did not always provide enough guidance for staff on how to safely support people. For instance, 1 person was administered PRN codeine on 14 July 2026 however the PRN protocol was written on 28 July 2026, the day after our first site visit.

There was a lack of oversight regarding medicines which needed additional storage and stock management due to their potential for abuse. We found not all medicine of this type were routinely checked to ensure the balance remaining at The Croft was correct. This was not in line with best practice guidance and the providers policy.