- Care home
Croft House Rest Home
We served a warning notice on Mr Sandeep Phull and Mrs Janet Hughes on 16 May 2025, for failing to meet the regulations related to safe care and treatment and good governance at Croft House Rest Home.
Assessment report published 25 June 2025
Contents
Ratings
Our view of the service
Date of assessment: 20 March to 31 March 2025. The service is a residential care home, supporting up to 22 older people and younger adults. At the time of our assessment, 20 people lived at the service.
This unannounced assessment was carried out to review compliance with the legal regulations. At the last inspection, the provider was in breach of the legal regulation in relation to governance. Improvements were not found at this inspection, and the provider remained in breach of this regulation.
At this inspection we found standards had declined; and identified a further 4 breaches to the legal regulations in relation to consent, safe care and treatment, safeguarding and staffing.
The registered manager did not ensure incidents were acted upon, learnt from or shared appropriately; and safeguarding processes were not always followed. Risks to people were not thoroughly assessed or reviewed, and staff did not have the training to fully understand and manage risk. Staff did not have the appropriate training to lead an emergency evacuation, and fire safety systems were not robust. Environmental safety checks were not consistently completed, and we identified several concerns with the safety and security of premises and equipment. Pre-employment checks were still not being carried out appropriately; and there was not always enough staff on duty to ensure safe, good quality care. Systems to maintain standards of cleanliness and hygiene were still not adequate, and medicines including controlled drugs were not managed safely.
People’s care plans were not always thoroughly completed, and information was not updated when people’s needs changed. The provider’s policies and poor levels of training meant we were not assured managers or staff always followed current best practice guidance. Systems and processes to share information and monitor people’s care were not effective, resulting in poor outcomes for several people. The provider still did not ensure decisions were made within the requirements of The Mental Capacity Act 2005 (MCA).
The provider did not provide enough access to regular, meaningful activities which impacted people’s wellbeing; and staff wellbeing was not always prioritised.
The registered manager, deputy manager and staff did not fully understand the diverse needs of older people or people living with dementia, and there was a lack of training in these areas. Complaints were not always thoroughly recorded or investigated. People were not always supported appropriately to make advanced decisions, and their end-of-life care was not recorded or regularly reviewed.
Managers did not have the appropriate skills, knowledge or capacity to lead effectively or ensure risks were well-managed, and staff did not always feel confident enough to speak up. Governance systems were still poor, and confidentiality had not improved. The provider did not always work in partnership with other local services; and current processes did not support learning, improvement and innovation.
However, people’s were kept informed of the provider’s terms and conditions. People and their relatives had the opportunity to give feedback and were confident concerns would be acted upon. People had access to care and support during an emergency; and reasonable adjustments had been made where required. Staff spoke positively about the new deputy manager; and the provider was responsive to feedback, taking action to address concerns.
In instances where CQC have decided to take civil enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.
We have asked the provider for an action plan in response to the concerns found at this inspection.
People's experience of this service
People and their relatives generally spoke positively about the service, and the care people received. Comments included, “I feel both comfortable and safe here. [Staff] look after me, they always make sure I’m alright,” “All the staff are very good and genuinely care about you” and, “On the whole, Croft House Rest Home has been fantastic.”
Relatives gave examples of how the service helped people to stay safe by managing risks to their health, mobility and medicines. One relative said, “[Person] has always been prone to falls but they have a stick now and are on the ground floor which is better.” Another added, “We were worried about [person] when they were at home, but they are better here, [person’s] put-on weight and we know they can’t get their medicines mixed up anymore.”
People confirmed they were supported with their healthcare needs and told us they enjoyed meals at the home. A person told us, “It’s not a restaurant but we have a reasonable range of good local produce.”
People told us staff were kind and caring, and staff were observed to be attentive and patient throughout our inspection. A relative said, “[Person] is so well cared for, [Staff] are like family.” Another added, “As a family we come and go as we please and see that there’s always good care.”
Relatives confirmed they were involved in the care planning process and kept informed when people’s needs changed. We observed people receiving person-centred care from staff who knew them well. People and relatives assured us they knew how to raise concerns and felt they would be listened to. One relative told us, “If we have any concerns or worries, the staff always listen.”
However, a couple of relatives commented on the ‘dishevelled’ appearance of their loved ones; and people indicated choices were restricted at times.
Whilst people we spoke with expressed, they were generally happy with their care, our assessment found elements of safety did not meet the expected standards.