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 inadequate. 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 in relation to safe care and treatment.

This service scored 59 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service established an incident recording process and staff recorded incidents. Leaders of the service commenced a process to review incidents such as falls, which required embedding to ensure any issues were identified and monitored.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The registered manager conducted assessments of people’s needs prior to admission to Croft House Rest Home, making sure staff could meet people's needs. Of their admission, 1 relative said, “They did everything to make [relative] comfortable; he was able to bring his own television, nothing was too much trouble.” Another person said, “Everything went fine, they made me feel very welcome.”

Information was shared between relevant people such as health professionals and members of the local authority.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 always share concerns quickly and appropriately.

The registered manager had not submitted abuse notifications to CQC which is their legal duty to do so. However, staff completed safeguarding training and knew how to report concerns. The registered manager worked alongside the local authority to make sure safeguarding incidents were shared and investigated and then collated and monitored.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. The management team made applications to the local authority when required and had a process to monitor these. Staff adhered to any restrictions that had been authorised.

The provider did not always work well with people to understand and manage risks. Care was not always provided in a way that met people’s needs in a safe and supportive way.

There were gaps in written guidance to outline risks to people’s health and wellbeing, and it was not clear whether risks were always monitored. There were 3 people with diabetes, however for 1 person there was no diabetes care plan or clear guidance to help staff manage the condition. Additionally, 2 further people required their blood sugar levels to be monitored 4 times per day, however this evidence had not always been recorded. This was a continued theme found at the previous inspection. We saw some discrepancies in care plans, for example information within 1 person’s nutrition risk assessment differed to information found elsewhere in the care plan, which could cause confusion about the level of risk. We did not find any evidence of harm, and the registered manager agreed to review and update written guidance immediately. We saw improvements following the previous assessment in written guidance regarding how to support people who experienced distress, and we observed staff responding to people positively.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

There was a robust maintenance system in place, and improvements were made to the environment following the previous assessment, for example with regards to fire safety. Health and safety compliance checks were in date, and the maintenance manager completed environmental audits to make sure items were fixed or replaced when needed.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective training and development.

At the previous assessment gaps in safe recruitment were found. Improvements had been made at this assessment, and the provider followed safe recruitment processes, for example checking references and Disclosure and Barring Service (DBS) checks.

Staff completed online training, however we found some gaps in training compliance rates, for example some staff had not completed training about how to support someone with a choking risk, and staff were overdue refresher training such as basic life support and fire warden safety. The registered manager agreed to arrange up to date training as soon as possible.

People said they thought there were enough staff on duty to meet their needs. Although not everyone used a call bell, the people that did said staff answered these quickly.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The home was clean and tidy; people told us staff cleaned their rooms every day and 1 person said, “They keep the home nice and clean, they clean my room, but I like to keep my room tidy.” We saw cleaning schedules in place and staff wore appropriate protective clothing such as aprons and gloves to minimise the risk of the spread of infection.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

We found that 1 person had received a medicine that expired, and for the same person, staff had not recorded when a liquid medicine was opened, therefore it was not clear whether the medicine had expired. This meant we were not sure whether the medicines were safe or effective to use.

Staff did not always sign medicine records to show people received their medicines as prescribed. Where people had time sensitive medicines such as paracetamol, records showed there was not always a 4-hour gap between doses as per safety guidance.

Some medicines were not stored securely. Staff did not always record the temperature of medicine storage areas. When the temperature was not in the correct range staff did not take action. We could not be assured that medicines were safe to use.

Although there was guidance regarding medicines given ‘as and when required’, staff did not always document the outcome and effectiveness of these medicines to support reviews by prescribers.

Information about people’s medicines was sometimes missing. For example, regarding the safe use and monitoring of Lithium.

There were some gaps in medicines awareness training, and several staff had not had their medicine administration competencies checked recently.

Although audits were being completed by managers these had not always identified the issues found during the assessment, and so we could not be assured these were effective. When external audits had been completed it was not clear whether staff actioned any of the concerns identified.

We did not find any evidence of harm, and the registered manager confirmed several actions would be taken to address all of the above. For example, the appointment of a medicines champion to take the lead, and improvements to the medicines audits and regular checking of guidance and information.

However, staff had good knowledge about people’s medicines and their preferences. People were supported to self-administer their own medicines if they wished. For 1 person who managed their own creams staff completed a risk assessment to ensure this was done in a safe way.