Croft House Care Home

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

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. At our last assessment we rated this key question Good. At this assessment the rating has changed to 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.

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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people. The manager was new into their post and had already identified areas to make improvements and started these processes in areas where needed. The manager told us they knew they did not have robust governance systems in place, and this was something they were in the process of improving. The manager was in the process of implementing an auditing matrix to ensure there were more audits taking place and more robust audits to ensure leaders had a better oversight. The service provided evidence of staff meetings and resident meetings taking place. Staff told us the staff meetings took place, and they were informative. The told us sometimes they felt listened to but other things were not listened to, mainly around staffing levels.

The provider had systems in place to capture the views of staff and people, such systems needed be operated in an open and transparent way the provider needs to demonstrate how they are listening and responding to staff. Some staff told us the change in management had been a good thing and the newly appointed manager seemed to be doing their best to improve the home. However, some staff said they had raised concerns to management in relation to staffing levels, food and activities in the home, but things were not changed in response to these concerns. Staff also told us their supervision was not always regular.

People did not always feel they could speak up and that their voice would be heard. The provider did have appropriate policies in place to support people to speak up. The provider also had whistleblowing posters up in the home and anonymous staff surveys were sent out. Staff told us they felt able to speak up if they needed and leaders were approachable. However, some staff said they had raised concerns to management in relation to staffing levels, food and activities in the home, but there had been no changes made in response to these concerns.

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 had appropriate policies in place. The recruitment and induction process embedded values that worked towards an inclusive and fair culture by improving equality and equity for the staff. This was then continued throughout their training and in meetings.

The provider had policies and procedures in place to support staff. During our assessment we found that the required safety checks had been completed but there were some gaps. There were gaps on the shower cleaning checks, profiling bed checks, sluice sterilising, some checks that had been completed had not been signed. Personal Emergency Evacuation Plans (PEEPS) and other fire safety checks were largely completed but simulated fire drills were not being completed within recommended timescales. During our assessment we found some auditing of care plans had been undertaken over the past 3 months. Those audits did not identify issues we subsequently found during our assessments. For example, audits had not identified gaps of longer than 4 hours on the repositioning charts for some people. Some risk assessments were not always fully accurate and required updating but this also had not been picked up during audits.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information with partners. During our assessment the provider had access to a regular GP practice, regular nursing team, regular chiropodist and hairdresser. No concerns were raised from people in relation to partnership working. Some of the comments were, “I go to the barbers”, “They would get a doctor if required and a doctor does come every Wednesday and do a clinic” and “They have a chiropractor here.”

The provider focused on learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. The manager was reporting safeguarding’s and investigating events and incidents and gathering lessons learnt using reflective reviews from incidents and events to improve. The required statutory notifications had mainly been submitted.