Croft Manor Residential Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

The service was in breach of legal regulation in relation to safe care and treatment, consent and good governance. People’s health, nutritional and hydration needs were not always effectively assessed, recorded, monitored or acted on, and care records did not consistently provide staff with clear and accurate guidance to deliver effective care and treatment.

This service scored 42 (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 make sure people’s care and treatment was effective because they did not consistently assess people’s health and care needs or ensure staff had accurate, complete and current information to meet those needs.

The provider did not consistently assess people’s health conditions or provide staff with the information needed to recognise and respond to deterioration. For example, 1 person lived with angina and heightened anxiety. Records identified anxiety as a trigger for angina attacks, but information relating to angina and respiratory management was not consistently reflected, cross-referenced or readily accessible within care planning documentation to support recognition of deterioration and escalation of concerns. For one person with respiratory conditions, records also contained conflicting information about whether the person self-administered their inhaler or whether staff were required to administer it. The absence of clear guidance increased the risk that symptoms of respiratory or cardiac deterioration may not be recognised promptly and that staff may not respond consistently in an emergency.

The provider’s care records also contained contradictory information about people’s mobility and pressure care needs. One person’s mobility care plan, dated 3 June 2026, variously stated that they were "confined to bed", "chair bound" and "fully mobile". The records also gave conflicting information about the equipment required for transfers, including a stick, Zimmer frame and full hoist. In addition, records gave conflicting instructions about repositioning, with 2-hourly repositioning recorded in the mobility and function risk assessment dated 5 June 2026 and 4-hourly repositioning recorded in the skin integrity care plan dated 3 June 2026. This created a risk of staff providing inconsistent support and meant the provider could not be assured the person was receiving care in accordance with their assessed mobility, transfer and pressure care needs.

The provider did not consistently plan and deliver people’s care and treatment in line with their assessed needs. Staff did not always have accurate information or effective systems to ensure people received appropriate dietary, nutritional and hydration support, and the provider did not consistently identify and respond to changes in people’s assessed risks.

The provider did not ensure staff understood and delivered people’s prescribed dietary and fluid requirements. Records showed 1 person had a SALT prescribed diet and fluid modifications. In addition, 4 other people were on modified diets either by choice or due to dental needs, but staff, including the chef, described people as being on a "soft diet" and were unable to identify the International Dysphagia Diet Standardisation Initiative (IDDSI) levels. A staff member described a person as being on a "L2 diet", which is not an IDDSI level. This demonstrated that staff did not consistently understand or implement people's assessed dietary requirements. As a result, people were at risk of receiving food that was not appropriate to their assessed needs, increasing the risk of choking and other complications associated with unsafe eating and drinking.

The provider did not consistently monitor or respond to significant nutritional risks. The manager told us that 1 person was at high risk of malnutrition. The person’s nutrition and hydration care plan, dated 9 June 2026, stated that they required significant prompting to eat, needed daily weighing due to recent weight loss and needed prompting to drink as they could forget. The same care plan also stated that the person no longer required a food chart because they had regained and maintained their weight for more than 2 weeks. However, the most recent malnutrition screening tool dated 11 February 2026, identified a score of 3, indicating a high risk of malnutrition, and stated that the person was on a food chart and being weighed weekly. Food charts reviewed from 12 to 18 June 2026 contained gaps and did not consistently record quantities provided or whether meals had been fortified. The care plan also stated that the person had been prescribed food supplements and required staff support to have these daily as prescribed. Despite the care plan suggesting the person's weight had stabilised, weight monitoring records showed the person continued to lose weight. This meant the provider could not demonstrate that the person's nutritional risks were being effectively monitored, reviewed or responded to, and there was a risk that further deterioration in the person's nutritional status may not be identified or acted upon in a timely way.

The provider did not ensure hydration risks were appropriately assessed and acted upon. The manager told us that another person was at risk of dehydration. However, there was no dehydration risk assessment and the person’s care records did not specify a fluid target. Their care plan stated that staff should monitor their fluid intake to maintain hydration due to progressive health deterioration, but records showed low fluid intake on multiple dates, including 0ml recorded on 8 days. This meant assessment and monitoring of the person’s hydration needs was not robust.

The provider did not have effective processes to identify and address inconsistencies in people’s care and treatment. Nationally recognised assessment tools contained conflicting assessments of risk. For example, 2 pressure injury risk assessments for 1 person contradicted each other, with 1 identifying a risk and the other assessing the person as having no risk. Similarly, constipation assessments produced substantially different risk scores for multiple people. This meant the provider could not demonstrate that people’s changing needs and identified risks were being effectively reviewed, acted upon and monitored to ensure their care and treatment remained safe and effective.

The provider did not always work well across teams and services to support people. Although there were established arrangements for communication and handover, information shared between teams and with other services was not always accurate, complete or up to date.

The provider did not consistently ensure information shared with other services was accurate and complete. People had hospital passports, which should provide important information about the person should they require hospital admission. These were not maintained with accurate, consistent or up to date information. For 1 person, the hospital passport contained contradictory information related to food allergies. The same passport stated the person had experienced no falls in the previous 12 months, despite recording multiple falls elsewhere, including 1 requiring hospital admission and another where paramedics attended. For another person, the hospital passport did not include key information such as their current medicines or general practitioner (GP) details, which were recorded as "Not recorded". Whilst current medicines information may have been available within accompanying transfer documentation, this information was not reflected within the hospital passport itself. This meant the provider could not demonstrate that accurate and complete information about people’s needs, risks and treatment would be available when they moved between services.

The provider did not consistently maintain and share current information between teams to support people’s nutritional needs. A nutritional needs report was present in the kitchen; however, this was not dated. The chef told us this had last been shared with them “probably 6 months ago”. This report contained information about 1 person who had died the previous week, another person who had not been at the service for approximately 6 months and did not include a person in the service for respite. This increased the risk that staff could rely on inaccurate or outdated information when providing people’s meals.

The provider had evidence of communication with various health and care professionals and input from partners was clearly documented. Staff shift handover records were detailed and included professional’s input. Staff we spoke to confirmed handover was effective with 1 staff member saying, “During every handover, we discuss everything, if there’s anything we can change and if there’s any changes.” This provided assurance that changes in needs and important updates were shared between shifts.

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.

The provider supported people to make healthier choices and maintain their health and wellbeing. Care plans promoted healthier choices and there was evidence that healthcare partners were contacted when people’s long term health needs changed. This meant people could access appropriate support to maintain their health and wellbeing and reduce the risk of their needs increasing.

The provider offered activities that supported people’s physical and mental wellbeing. The activities team provided chair exercises and games designed to stimulate people’s cognitive abilities. We observed activities being delivered with energy and enthusiasm, with people encouraged to participate at their own pace. This supported people to remain active and engaged in ways that promoted their physical and mental wellbeing.

People and relatives spoke positively about the support provided to maintain health and wellbeing. People told us, "If I wanted them to [support with wellbeing], they would." and another person told us, “They cheer me up when I’m down. They explain things to me.” Relatives also spoke positively about the service’s commitment to improve people’s lives. One relative told us physiotherapy had been booked and that 1 person had completed exercises 3 times a day. Another relative described how staff responded when a person initially refused to sleep in their bed, saying, "they came up with a plan... Now she sleeps in her bed." This demonstrated that staff responded to people’s individual needs and preferences and supported them to maintain or improve their independence and wellbeing.

A healthcare professional also spoke positively about people’s experience of the service, telling us, “The atmosphere within the home is warm and cheerful, and the residents appear happy, comfortable, and well cared for. It is clear that the staff make a genuine effort to engage with residents and support their wellbeing.” This provided independent corroboration that staff actively promoted people’s wellbeing and engagement.

The provider did not routinely monitor people’s care and treatment effectively to identify whether planned care was being delivered and whether changes were needed to improve outcomes. They did not consistently ensure that care was delivered in line with people’s assessed risks or that changes in people’s clinical condition were identified and responded to appropriately.

The provider did not consistently monitor whether people at high risk of pressure injuries received care in line with their assessed needs. For example, 1 person who required a full hoist for transfers had been assessed as being high risk of pressure damage and the skin integrity care plan required repositioning every 4 hours. However, repositioning records from 1 to 7 June 2026 showed several gaps of up to 11 hours and 30 minutes without repositioning, with no documented refusal or explanation. A second person who required a full hoist for transfers had conflicting assessments of their pressure damage risk recorded within their care records. Repositioning records from 1 to 7 June 2026 showed several gaps of up to 16 hours without repositioning and no documented refusal or rationale. This meant the person's risk of pressure damage was not being effectively monitored or managed.

The provider did not consistently monitor and respond to changes in people’s clinical observations. For 1 person, the recorded baseline National Early Warning Score (NEWS) was 0, but records showed NEWS scores above baseline on 12 September 2025, 20 January 2026 and 6 May 2026 without evidence that observations were repeated or escalated in line with the provider's arrangements. The provider told us staff were expected to increase monitoring and repeat observations where scores were elevated, however monitoring was not increased. This meant the provider could not demonstrate that potential deterioration in the person's health had been recognised, monitored or responded to promptly, increasing the risk that changes in their condition may not be identified in a timely manner.

The provider did not always tell people about their rights around consent and did not consistently demonstrate that people’s rights were protected when restrictive practices or care arrangements were implemented.

The provider did not consistently obtain appropriate consent or complete Mental Capacity Act 2005 (MCA) and best interests BI assessments for monitoring, impacts privacy, and modifications to dietary arrangements. Three people with cognitive impairment were receiving modified dietary arrangements due to dental problems or deterioration; however, records reviewed did not consistently demonstrate that decision-specific MCA and best interest processes had been completed where required. Where people lacked capacity to consent to these arrangements, the provider could not demonstrate that decisions had been made in accordance with the principles of the MCA, that the person’s wishes and feelings had been considered, or that the least restrictive option had been used. This meant people’s consent, capacity and rights had not always been appropriately considered before care arrangements were implemented.

However, people and relatives described positive experiences of being involved in decisions about their day-to-day care. A person told us, "They always tell me what they're going to do and ask if it’s ok before they do it.” A relative told us, "They ask her what she would like," and another told us staff would say they would return in half an hour, and the person usually agreed. This demonstrated that staff generally sought people’s agreement and involved them in routine interactions.

A healthcare professional also provided positive feedback, telling us that whenever they visited the home, “Staff do take their time to actively listen to any questions asked. Staff gain consent to activities, personal care, meals being served etc.” This provided independent corroboration that staff generally sought consent and listened to people during day-to-day care.