Croft House Rest 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

Safe – 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 inadequate.This meant people were not safe and were at risk of avoidable harm.
The service was in breach of legal regulation in relation to safe care and treatment, safeguarding and staffing.

This service scored 28 (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 proactive and positive culture of safety, and lessons were not learnt to continually identify and embed good practice.
The provider’s systems and processes to investigate, report and learn from safety incidents were not robust and appropriate action was not always taken following an incident or accident. For example, there had been 13 incidents in which a person displayed distressed behaviour, in which other people and staff had been subject to verbal abuse and physical harm. Behavioural records had not been thoroughly reviewed in an attempt to identify themes and trends, and there was a lack of action taken following incidents to reduce the risk of re-occurrence.
We reviewed records for incidents which had resulted in skin tears and fractures, several of which had not been reported to the appropriate partners. The registered manager and deputy manager had not always referred to local guidance to aid their understanding of reportable incidents and ensure duty of candour.
People’s falls records had not been kept up to date, or reviewed consistently to ensure appropriate measures were in place to prevent further incidents.
Since our feedback, the provider has sourced additional training for staff in relation to record keeping and reporting of incidents, and implemented a system to ensure documentation is updated following an incident or accident.

The provider did not always work well with people to establish and maintain safe systems of care, or and ensure there was continuity of care when people moved into the service.
People’s pre-admission assessments were not always thoroughly completed prior to people moving into the home, to ensure staff fully understood people’s health and care needs, and any associated risks. One person had not had a pre-admission assessment completed, and others had not been completed in full. This placed people at risk of not receiving care in line with their needs and preferences upon admission to the home. A staff member told us, “There’s a handover and [hospital] discharge sheets are shared with staff, but no assessments are shared.”

The provider did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.
The provider’s systems and processes to make sure people were protected from abuse and neglect were not robust. A concern of neglect raised by a family member had not been formally recorded, investigated or shared with the appropriate partners. Several other incidents of verbal and physical abuse had also not been shared, and appropriate action had not been taken to prevent further harassment or abuse.
Staff were aware of the signs of abuse, but several staff had not completed safeguarding training as per the provider’s own policies. Some people at the home had restrictions in place or lacked capacity. However, training in Deprivation of Liberty Safeguards (DoLS) and Mental Capacity Act 2005 (MCA) was not available to all staff, to support their understanding of people’s human rights and ensure people received care in line with these.
Following our feedback, the provider has implemented a new package of training and provided assurances staff training had been reviewed, and ongoing improvements were being made.

The provider did not work well with people to understand and manage risks, or ensure care provided met people’s needs safely.
Managers did not always ensure risks were assessed or reviewed to reflect changes to people’s health, care or behavioural needs. People with a diagnosis of diabetes, did not always have robust care plans and risk assessments. Information in a person’s care plan stated, ‘Staff are to have a full understanding of [person’s] diabetic needs and the signs and symptoms of Hypoglycaemia or Hyperglycaemia.’ However, details about their diabetic needs were not recorded; and several staff did not have the appropriate training to support guidance and ensure they had a good understanding of Hypoglycaemia or Hyperglycaemia.
When people communicated their needs, emotions or distress staff could not always manage this positively, or maximise learning to prevent future episodes of distress. We observed a person being verbally abusive towards staff and other service users during our inspection. Their care plan and risk assessments lacked detail about any distressed behaviours, and did not provide adequate strategies to guide staff on how to prevent or respond to signs of agitation in an agreed, person-centred way. Records demonstrated a poor understanding of their dementia diagnosis and associated behaviours, placing people at risk of not receiving effective care in line with their needs.
Several staff had not received training in dementia, and the provider did not offer further training to ensure staff could understand and support people’s associated behaviours safely. A staff member told us, “I have had no training in dementia or distressed behaviours.”
Since our feedback, the provider has sourced additional training around positive behavioural support.

The provider did not detect and control potential risks within the care environment, or make sure that equipment, facilities and technology supported the delivery of safe care.
The provider did not ensure there was enough competent staff to manage a safe and efficient emergency evacuation; putting people, visitors and staff at risk of avoidable harm. The home did not have any trained fire wardens to lead an evacuation, and drills had not been attended by all staff. There was equipment available to move people downstairs during an evacuation, but staff were not trained to use it safely. The service’s fire risk assessment had not been reviewed as recommended, and fire safety checks were not consistently completed.
The provider’s arrangements to monitor the safety and upkeep of the premises and equipment were not effective. For example, flooring was uneven in places, an unstable bed lever was in use and wardrobes were not fixed to the wall; increasing the risk of falls or entrapment. Doors to the basement and laundry room, and external fire escapes were not appropriately secured; posing a risk to people living with dementia.
Safety checks to mattresses, bed rails and bed levers were not in place; and other checks had not been carried out since August 2024. Water outlet flushes and temperature checks had not been consistently completed to minimise the risk of legionella, placing people at increased risk of harm.
The training matrix evidenced several gaps to health and safety, and moving and handling training; placing people at risk of not receiving consistently safe care.
Following our feedback, the provider took steps to secure wardrobes, refresh the fire risk assessment, improve training and implement new health and safety checks.

The provider did not make sure there were enough safely recruited, qualified, skilled and experienced staff.
The provider did not always ensure pre-employment checks were carried out in line with current best practice guidance. A staff member did not have a current Disclosure and Barring Service (DBS) check, and references were not available for us to review. DBS checks provide information including details of convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.
Staffing levels were not always adequate to ensure people received consistently safe, good quality care. Rotas evidenced extended periods of time when only 2 staff members were on duty, yet several people required 2 staff for assistance with personal care or moving and handling. This meant there were times when no staff were available to provide supervision in communal areas, or respond quickly if people needed immediate help or support. A staff member said, “[Staff] can't keep an eye on people who are moving around if we are getting people up. It can be bedlam.” Another added, “Every now and then if something happens it can be tricky.”
Staff did not always receive training appropriate and relevant to their role, or have their competencies assessed in line with the provider’s own policies or current best practice guidance. The provider’s training matrix evidenced multiple gaps, and a staff member told us, “There hasn’t been a lot of training, I’m not going to lie.”
We received mixed feedback about the frequency of supervisions. However, staff generally felt supported by managers. A staff member told us, “[The deputy manager] is lovely. [The registered manager] is only upstairs, they would offer support if we went and asked.”

The provider did not assess or manage the risk of infection or detect and control the risk of it spreading.
People were not always protected from the risk of infection because premises and equipment were not kept clean and hygienic. Staff undertook housekeeping duties at the home, alongside their caring responsibilities. However, it was evident from standards of cleanliness observed, records reviewed, and staff feedback; they did not always have capacity to ensure good standards. The kitchen, medicines trolley and other areas of the home required a deep clean, and there was a strong malodour noted on several occasions during our inspection. A staff member said, “There’s a couple of designated cleaning shifts but it’s not adequate.” Another added, “We clean during night shifts but can only do so much, sometimes it’s hard.”
There were areas of the home where paint was chipped, wallpaper was peeling or flooring was cracked, making surfaces harder to clean and impacting good infection prevention and control (IPC).
People were not always adequately supported with their personal hygiene. There were large gaps to people’s records so we could not be assured people were given regular support with personal care. A relative told us, “When I visit [person] they look a bit dishevelled. I gave [person] an electric razor but I don’t know where that’s gone.”
Since our feedback, the deputy manager organised a deep clean of the kitchen, and the provider reviewed staff training and replaced cracked flooring in the laundry room.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.
The provider’s approach to medicines did not reflect current best practice guidance. Half of people living at the home did not have a medicine’s profile page in place to support the safe management of medicines, or prompt staff around people’s specific needs and preferences. As required (PRN) guidance was not available for all PRN medicines in use, and the reason for administering PRN medicines was not recorded to aid reviews.
Prescribed topical creams were not stored securely or adequately recorded; and were not dated upon opening to ensure they could be disposed of within the manufacturer’s recommendations.
Room and fridge temperature checks were not carried out or audited in line with current best practice guidance, meaning medicines could have spoiled or become ineffective.
The provider did not have the appropriate arrangements for the safe management and oversight of medicines, including controlled drugs. A person was prescribed a controlled drug but appropriate records had not been updated with the correct stock balances when the medication was received into the service. One dose had been used, but from records we could not identify when or why the medication had been administered. Other medicines did not include stock balances, making it difficult to effectively monitor medicines and identify any errors.
The registered manager, deputy manager and several other staff responsible for administering medicines had not received up to date medication training, or had their competencies assessed.
Following our feedback, medicines information was updated, a new cupboard was purchased to store people’s topical creams, the system for recording controlled drugs was reviewed, staff training and competencies were refreshed and temperature checks were introduced.