Croft House Rest 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

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.
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.
Please note we did not review Shared direction and culture or Workforce equality at this inspection. Information has been incorporated from our last inspection of the service.
The service had a continued breach of legal regulation in relation to good governance.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not ensure managers had the experience, capacity or capabilities to ensure the organisational vision could be delivered and risks were well-managed.
The registered manager was unaware of some of the concerns we raised during our inspection, and the associated risks. For example, when we provided feedback about the management of people’s distressed behaviours, they did not understand the impact of staff not having access to the appropriate information or detailed strategies.
There was limited evidence of ongoing support and development available to them, to ensure they could lead effectively.
A deputy manager had been appointed several months before our inspection, and staff commented positively about their capabilities and contribution to the team. A staff member said, “[Deputy manager] is skilled.” Another added, “[Deputy manager] does a lot. I do believe they are helping pick things up, they had managed homes before.” Whilst the deputy manager was dedicated to making the required improvements to the quality and safety of care, they did not always have the capacity to do so, alongside their caring responsibilities. They had not received training or a formal induction since being employed at the home; which impacted their understanding of the provider’s systems and processes, and the requirements of the role.
Following our feedback, the provider gave assurances that the deputy manager would be given more protected time for administrative and management tasks, and additional training was provided to both managers.

The provider did not ensure staff felt able to speak up and their voices would be heard.
Managers did not always actively promote staff empowerment to drive improvement, or encourage staff to raise concerns. A staff member told us, “[Registered manager] doesn’t always listen if we try to put suggestions across, their way is always right.”
The registered manager did not offer regular opportunities for staff to share concerns; supervisions and team meetings were not held regularly, and we did not see evidence of staff surveys or feedback forms.
Staff were not always confident their voices would be heard. We received mixed feedback about the responsiveness of the registered manager, to new ideas or change. A staff member told us, “I think the managers are very approachable,” but another said, “What I like least [about working at Croft House Rest Home] is I can’t have a voice.”

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.
The provider’s systems to manage performance and risks to the quality and safety of the service were not robust. Audits and checks to records, equipment, health and safety, IPC, medicines and training were not consistently completed; and failed to identify or address concerns found during our inspection.
The provider employed an external auditor to review records and improve governance at the service; but managers could not confirm the frequency of visits, past findings or action taken to address concerns.
The provider did not have robust arrangements for the availability, integrity and confidentiality of date and records. We asked to review several records including the training matrix, cleaning records and complaints file but these were not readily available at the time of our inspection. People’s care plans and personal information was not kept confidential. Their DNACPR status and weights were displayed on a notice board in the lounge, and the office where people’s care plans were stored was left unlocked and unattended frequently during our inspection.
Information in people’s care plans and risk assessments was not always complete or contemporaneous, and care records were poor. This meant it could not be used effectively to monitor and improve the safety and quality of care.
Data and notifications were not always submitted to the appropriate partners following incidents or concerns of abuse.

The provider did not always understand their duty to collaborate and work in partnership with other services, or share information and learning with partners to collaborate for improvement.
Managers and staff did not always work in partnership with key organisations to support care provision or service development. A partner told us, “I don’t think [Croft House Rest Home] have attended our care home events.”
The deputy manager advised they had not been involved in any local groups or forums due to their own workload and capacity.
However, the home did support people to attend some community-based events and services such as Macmillan coffee mornings, local parades and the library.

The provider did not focus on continuous learning, innovation and improvement or encourage creative ways of delivering equality of experience, outcome and quality of life for people.
Systems and processes to ensure learning happens when things go wrong were not robust; or used to measure outcomes or the impact of change. Incidents were not always thoroughly investigated, shared or acted upon to improve people’s future outcomes. Please see the ‘Learning culture’ section of this report for more details.
Staff were not supported to priorities time to develop their skills around improvement and innovation. An IPC champion role had been created in response to the local authority IPC team recommendations. It was unclear what additional training they had to prepare them for the role, and they had not maintained attendance at forums to keep themselves or the service updated about changes to best practice guidance.
The provider did not have strong external relationships that supported improvement and innovation. We reviewed past inspection reports and feedback from external partners and found recommendations had not always been followed. For example, at our last inspection we raised concerns with recruitment systems, consent, confidentiality and checks on the safety and quality of care; but found similar concerns at this inspection.
Since our inspection, the provider has been responsive to feedback and has taken action to address several key areas of concern.