The Croft

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 assessment for this service since a change of provider in October 2025. This key question has been rated requires improvement. This meant the 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 a legal regulation in relation to governance at the service.
 

This service scored 61 (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 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.

Staff were provided with the vision and values of the company. Systems and processes were in place to communicate any changes in these to staff. The provider produced regular information bulletins for staff.
 

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge, experience to lead. However, the registered manager was not at The Croft and had left earlier in the year. Another manager was in post to cover day to day oversight, and it is the intention they will apply to be the registered manager.

The provider had been responsible for The Croft since October 2025. We noted the oversight and monitoring was not always effective in driving improvement. The manager and provider had not identified all the concerns we found.

However, staff described the manager as approachable. We received mixed feedback on the management from people and relatives. Positive comments included, "The new manager is very proactive”, “The manager seems nice", "We can talk to manager, deputy and team leaders and they are always available" and "Some excellent steps forward." However, other comments included, "Communication could be better", "We do feel we are in the dark, walking in treacle”, “We have only met the manager once" and “The consistency of everything is not there."

We have given feedback to the provider to ensure people and relatives feel updated and communicated to.
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Systems were in place for staff to speak up. Staff were able to speak with senior managers when they visited the service without fear of redress. The provider informed staff of their whistleblowing policy and procedures during their induction period. One member of staff told us, “I feel listened to and my view are taken onboard.”
 

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider operated equal opportunities for staff, systems were in place for all staff to be respected and valued. One member of staff told us they felt able to raise concerns and felt valued.
 

The provider had clear responsibilities, roles, systems of accountability. However, we found these were not always effective. We found the oversight and monitoring of the service had not identified the concerns we found.

People’s records were not always accurate and complete. Staff had completed medicine risk assessments however, they had not included high risk medicines such as emollients.

Daily records were not always accurate, complete or contemporaneous records of the support people received. For instance, daily records did not record how people were supported to move from a bedroom to a lounge. In addition, people’s records did not always record if they had been offered drinks. One person’s records stated, “monitor my food and fluid intake and report any concerns.” Daily records indicated the person had been offered and consumed 100 ml of fluid on 22 July 2026. This was especially concerning as this day was during the recent hot weather. Another person’s records daily notes showed they had been offered their first drink of the day at 15.58. Where people were on restricted fluids for medical reasons, records showed they had exceeded the recommended amount. No record was made of any remedial action or medical advice. This had the potential to place the person at risk of harm.

People’s records were not always representative of the individual. For instance, we found inconsistencies in people’s care plans. Care plans contained contradictions. Mental capacity assessments were not completed in line with the MCA or associated code of practice. Risks were not always assessed and mitigated which increased the likelihood of harm to people. Medicines were not always managed in line with best practice guidance.

The provider did not always ensure policies and procedures were followed. For example, a falls management policy was in place, which stated, a falls risk assessment should be in place and reviewed following a fall. We found this was not the case for all people who had fallen.

There was a lack of effective oversight at the service. The manager shared an action plan with us, which did not cover the issues we found at the service. However, some issues had been highlighted such as the need to update mental capacity assessments. We found delays in ensuring people lived in a clean, risk-free environment. This meant there was an increased risk actions identified were not addressed promptly to ensure people’s safe care and treatment.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider had worked closely with the landlord of the building and the local authority. The manager had forged links with the local community and had plans in place to extend this. The Croft was currently holding a raffle for a local charity supporting children.
 

Systems in place did not always drive improvement at The Croft. We found lessons learnt were cascaded to staff. However, the provider’s quality assurance systems were not used effectively to continuously improve the service. They had not consistently recognised gaps in risk assessments and improvements required in medicines records.

The manager was working with external agencies on a nutritional improvement programme which aimed to ensure freshly cooked food was provided to each person.