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 requires improvement. At this assessment the rating has remained 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.

The service was in breach of legal regulation in relation to good governance.

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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The management team fostered a positive and encouraging culture within the service. Staff were complimentary about their managers and felt well supported. Staff told us they attended meetings where they shared ideas and what they felt could be improved; staff said they felt listened to, enjoyed their jobs and were proud of the care they provided.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

There was a positive culture at Croft House Rest Home, and managers were visible within the service, being available at any time of the day. However, we noted that the documented gaps identified during the assessment had been missed. We were assured this would be dealt with by the provider.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had a whistleblowing policy and there was relevant information in staff areas about how to raise concerns. Staff said they would raise any issues if necessary and were confident they would be listened to and addressed.

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.

There were appropriate policies and staff completed equality, diversity and inclusion training. Staff did not report any concerns and felt they were treated fairly.

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 registered manager did not make sure that abuse statutory notifications were submitted to CQC which is their legal duty to do so. However, other types of notifications were made including deaths and DoLS.

Although the provider was undertaking audits about the service, these did not identify or action concerns found during the assessment, for example with regards to medicines management and gaps in written guidance around risk. Additionally, some audits were overdue. There was no evidence to show the service undertook fire drills, which was also found at the previous assessment.

Leaders had not identified gaps in monitoring of some people’s health conditions, such as monitoring weight, and blood sugar levels for people with diabetes.

We did not identify any harm as a result, and the provider confirmed that governance processes would be strengthened to make improvements.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The local area had a strong sense of community, which Croft House Rest Home benefitted from. There were several links including with the local churches and schools. Pupils visited people at the home and sang Christmas carols together, which people said they valued.

Another example was participation in a local ‘club day’ which people could be involved with and help plan activities. This meant people could remain involved in their local community as some people lived in the area a long time.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and the local and wider system.

Although quality assurance systems were in place, they did not always achieve the desired outcome of identifying issues and concerns, and this was a missed opportunity to make improvements.

However, improvements and developments were made following the previous assessment, for example moving from paper record keeping to electronic care planning, which both leaders and staff confirmed was a successful move.

The registered manager and deputy manager kept up to date with current guidance about best practice and attended forums and conferences where possible.