Croft House 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

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 regulation 12 safe care and treatment and regulation 18 staffing.

This service scored 47 (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 positive culture of safety. The manager investigated and reported safety events. Reflective reviews were carried out after events to learn and embed good practice. Accidents and incidents were being recorded by staff. Accidents and incidents were logged by the manager and had reflective reviews completed by the manager to support lessons learnt. Staff told us they could raise concerns around safety if required. Comments included “[Manager] does listen to concerns” and “Yes the manager does investigations”.

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. During this assessment people told us the transitions to and from the home were not always good. One person told us “[Relative] was admitted to hospital, and we did not know, and [relative] also went with no contact details, so the hospital were unable to contact us” and “When [relative] arrived here, they required a 72-hour continence test they were very delayed in doing this, luckily its sorted now".

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 had a safeguarding policy in place and safe and effective safeguarding practices in place to ensure people were protected from harm or abuse. During our assessment we found safeguarding and complaints were investigated and responded to. The required statutory notifications had mainly been submitted.

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. We identified some people’s needs were not met in respect of management of their skin integrity, continence and mobility. This had not always been identified in audits that the service had undertaken. This put people at risk of being harmed and/or their health and wellbeing deteriorating. People told us they did not always feel safe with the care received. Some comments were “My [relative] is supposed to have one to one as they have a specific way they need to go to the toilet. The agency staff don’t know how to do it correctly” and “At the moment they are supposed to be trailing new incontinence pads for [relative] but they [staff] haven’t even opened them yet”.

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. During the assessment inspectors observed the environment was not to a high standard. In the nursing wing for people living with dementia, there were holes in the wall, a door did not have a door handle and there was a loose screw which was a potential risk to people, there was a fire door unable to close and which had a loose screw. In the residential unit inspectors found exposed pipes in a bathroom, an electrical plug socket in the lounge area that was discoloured and cracked. A fire door upstairs had a padlock on the fire door and staff were unaware of the code to unlock the padlock in the event of a fire. Throughout the home painting and décor was not to a good standard. People told us they were unhappy with the environment. Comments included, “The maintenance here is rubbish”, “The double socket in my [relative’s] bedroom was hanging off the wall and wires were exposed, it took a week to mend after reporting it”, “The bath has been broken for two years” and “The building is dire.” The provider told us that decorators were booked to come to the home. There were maintenance improvements taking place during our assessment and safety concerns raised around the environment were rectified during our assessment.

The provider did not 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 observed that staffing levels were insufficient and this impacted on people. For example, a person who required the assistance of moving and handling equipment was unable to eat breakfast in the dining room due to insufficient staffing levels. An agency senior care worker was unable to administer prescribed cream to a person due to insufficient staffing levels. During the assessment inspectors observed a housekeeping staff member supporting people? at breakfast, when inspectors asked the staff member about this, the staff member said, “There are not many staff members and when I see staff struggling, I come off cleaning to help them. Cleaning can wait until after I’ve helped.” Inspectors found staff appeared rushed and did not have the time to interact with people. People mainly told us there were not enough staff. Some comments were, “Staffing levels are not adequate”, “They need to review staffing”, “There is not enough staff to share around, shortage of man power”, “The regular staff are good, not good agency staff they are terrible” and “The regular staff are very good but they are so busy they have not got time to spend with the residents, they [residents] are not supervised in the lounge as the carers are going from job to job.” Staff mainly told us there were not enough staff to support people. Some comments included, “With staffing levels sometimes it’s a struggle and we have a lot of agency staff at minute which makes it harder”, “There is not always enough staff to support with meal times sometimes other staff such as activity staff help us but they don’t always” and “It can feel like a struggle on a lot of shifts especially when something happens it doesn’t always feel like we have enough staff".

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. There was an infection, prevention and control (IPC) policy in place and the management team were clear on the IPC procedures required and their responsibility to provide Personal Protective Equipment (PPE). However, we observed some areas, mainly in bathrooms, that were an IPC risk. For example, the shower room was unclean, and we found used gloves and dirty underwear on the floor. Two toilets were unclean, one had faeces on the toilet seat, and the other had faeces on the sink. Inspectors also observed a person’s ensuite was left unclean with a catheter in the sink and blood left in a plastic jug on top of the toilet. We got mixed feedback from people in relation to infection, prevention and control but most people were dissatisfied with the cleanliness of the home. Some comments included, “ My [relative’s] room could be cleaned better, and their bathroom could be cleaned better, staff leave stuff in the sink”, “There has been soiled underwear left in their bathroom”, “My [relative’s] duvet cover was upside down and open at the top it was smelling and needed a wash”, “Cleanliness is ok”, “My room is clean”, and “When the next room uses their toilet it comes up in my [relative’s] toilet, it is not infection control".

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. We found that the home had some processes and systems in place to ensure people were receiving their medicines. However, some improvements could be made to ensure people received person-centred care. For example, people that were prescribed ‘when required’ pro re nata (PRN) medicines they did not have an in-depth person-centred PRN protocol in place. The protocols lacked detail and did not give staff sufficient information so staff would know which medicines and dosage was required. During the assessment we observed medication administered late throughout the day due to the morning medication round finishing at 12.45pm. During the same medication round the agency staff member administering medicines on two occasions was interrupted and pulled away from their medicines administration duties to attend another task. We also observed a person’s medication without a prescription label on the box in the medication trolley. The agency worker did not offer any PRN medication to any people throughout the medication round. They told the inspector they were unable to locate the PRN protocols, and were unsure which medicines were required. During the assessment we observed on the provider’s medication system that one person did not have the 4-hour gap between paracetamol as required. People did not raise concerns with how their medication was managed. One relative said, “They is on medication, and they stay with her while they take it”.