Croft Manor Residential 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 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 and good governance.People were exposed to avoidable risks because medicines, infection prevention and control, and other safety processes were not consistently assessed, managed or monitored effectively.

This service scored 47 (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 consistently demonstrate effective systems for reviewing, reconciling and learning from safety incidents. Whilst actions were taken following some incidents, the provider could not consistently demonstrate that learning was formally analysed, monitored and embedded across the service.

The provider did not effectively learn from repeated safety incidents. Statutory notifications identified 4 falls resulting in fractures in the last 12 months. Records showed that 1 person identified as having suffered a fracture in the last 2 years, had experienced recurring falls, with up to 3 falls involving emergency services and 1 hospital admission recorded during May 2026. However, the provider’s accident and incident audit and falls tracker did not demonstrate robust thematic review of incidents or identify how learning had been used to reduce the likelihood of recurring falls or similar incidents. This meant opportunities to identify recurring risks and take action to improve people’s safety were missed.

The provider did not have effective oversight of safety incidents and did not consistently ensure incidents were identified, investigated and reconciled across its recording systems. For example, on 10 June 2026, we identified an open incident record in the provider’s electronic system relating to an epileptic seizure recorded by a staff member in a person's daily notes on 26 April 2026. We raised this with the manager, who told us they were unaware of the incident because staff completed accidents and incident forms on paper. The manager subsequently investigated the incident and told us the person had not had a seizure, but the electronic record had been created by a member of staff in error. This demonstrated that incidents recorded across different systems were not consistently identified, reviewed and reconciled. As a result, there was a risk that safety concerns could remain unidentified or not be investigated and acted upon promptly.

Staff feedback supported our findings that learning from incidents was not embedded in practice. One staff member told us, "Previously we used to do lessons learned, every time we had an accident we used to find out the root cause, we have stopped doing this now." This was consistent with our review of incident records and falls audits, which did not demonstrate effective reconciliation, thematic review or evidence that learning from incidents had been used to drive and sustain improvements. The provider told us they had implemented a single reconciliation and closure process after the inspection.

The provider did not always establish and maintain safe systems of care. They did not always manage or monitor people’s safety effectively or ensure that information about people’s needs and risks was available promptly to support safe and effective care.

The provider did not consistently assess people’s needs and risks promptly following admission. For example, a person admitted for emergency respite in December 2025 did not have several key care plans and risk assessments completed until several months after their admission. These included assessments relating to nutrition, falls and mobility. We also identified gaps in the availability of pre-admission information for 2 other people. This increased the risk that staff would not have timely and accurate information about the person’s needs and risks to inform their care and support.

Staff feedback supported our findings. One member of staff told us, "Before [people] move in, [managers] create a care plan, staff read and have to sign. Sometimes the care plans are not very completed but still it's helpful." This indicated that staff did not always have fully completed care plans available to support them to understand and respond to people's individual needs.

People and relatives nevertheless described positive experiences of admission and transition into the service. A person told us, “We had a nice talk when I came... the people who talked to me were so nice and that makes a difference.” A relative said, “The interview with them was very thorough and they showed me the room [person] would be going into.” This demonstrated that people could experience welcoming, reassuring and person-centred transitions into the service.

Healthcare professionals also provided positive feedback about the provider’s communication and partnership working. A healthcare professional told us, “Yes, this care home usually makes referrals in a timely manner if required. I would hand over any relevant information to support a referral.” This indicated that, where healthcare input was required, the provider generally worked appropriately with healthcare partners to facilitate referrals and information sharing.

The provider did not always have effective oversight of safeguarding concerns. Although concerns were referred to the local authority in a timely manner where required, records did not consistently show whether concerns had progressed to a statutory enquiry, or clearly record actions taken, outcomes, lessons learned and closure dates. In addition, the provider’s safeguarding self-audit tool dated 18 May 2026 identified 2 actions, but there was no recorded outcome or sign-off for either action. This meant the provider's safeguarding records and governance systems did not consistently evidence progression, outcomes, learning and closure of concerns, limiting the provider's ability to demonstrate effective oversight and learning.

The provider did not adequately assess the risks for a person relating to their safety when accessing the community. The person’s risk assessment identified a high risk of an individual approaching them in the community. It stated that staff should accompany the person and carry a mobile phone to contact the police if required. It did not provide clear guidance about how staff should respond if the individual was seen or approached the person, or what measures should be taken to reduce the likelihood of this occurring. This meant that, although the risk had been identified, the provider had not translated the identified risk into sufficiently detailed control measures or guidance for staff to support the person safely in the community.

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. We found that the provider's arrangements for DoLS provided assurance that people were receiving care under appropriate legal authority. The relevant statutory documentation was available for the 3 people reviewed and there were no conditions attached to the authorisations.

People and relatives told us they felt safe, with 1 relative telling us, "[Person] is comfortable, safe and well looked after." The provider had an in-date safeguarding policy, staff training records demonstrated completion of safeguarding training, and staff we spoke to understood that safeguarding was intended to protect people from abuse. This provided assurance that staff had an awareness of their safeguarding responsibilities and was consistent with people’s and relatives’ experience of feeling safe.

The provider did not consistently assess or manage significant risks to people's health and safety. Staff did not have clear guidance to support people safely and manage identified risks effectively.

Staff did not always have the information or guidance needed to identify, understand and respond appropriately to significant risks to people's safety. For 1 person at high risk of choking, their ‘choking and dysphagia risk assessment’ and ‘eating and drinking checklist’, contained contradictory information. Records showed the person chose to eat high-risk foods and drinks outside their Speech and Language Therapy (SALT) prescribed diet and fluids. The person had capacity to make decisions about their diet and had chosen to accept the associated risks; however, the provider had not identified or agreed sufficiently robust measures to reduce the foreseeable risk while respecting the person's choice. The provider relied on the person using their call pendant if they experienced choking but had not identified robust contingency measures to manage the risk if they were unable to do so. There was no clear guidance setting out how staff should respond or what alternative arrangements should be used if the person was unable to summon assistance.

We also found one person who had been assessed by staff as requiring an IDDSI Level 6 soft and bite-sized diet due to deteriorating health and dental problems, had been served coleslaw salad, against the IDDSI level 6 requirements. This meant there were insufficient measures in place to mitigate a significant and foreseeable risk of choking and created a significant risk of avoidable harm.

The provider did not ensure people’s diagnosed conditions were consistently reflected in their care records. For example, 1 person was epileptic and prescribed epilepsy medication, but at the time of our inspection epilepsy was not recorded as a medical condition in their electronic care records and there was no epilepsy care plan, seizure management risk assessment or escalation protocol. Another person’s care plan listed epilepsy as a medical condition, but there was no epilepsy care plan or escalation protocol for epilepsy or seizure management. Without documented guidance, the provider could not demonstrate that staff had consistent information available to support safe and appropriate responses to seizure activity or changes in the person's condition.

The provider did not provide sufficient guidance to support effective diabetes management. One person was insulin dependent and received insulin from a district nurse (DN) once a day. Care plans did not provide sufficient guidance about what staff should do if the person’s blood glucose levels became too high or specify the person’s normal range. A staff member told us the person’s blood glucose levels had "been all over the place" and could range from 15 to 35 mmol, resulting in the diabetic nurse recently increasing the person’s insulin dosage. In the absence of clear guidance, the provider could not demonstrate staff had been provided with the information needed to recognise when readings were outside expected parameters, respond appropriately to significant fluctuations in blood glucose levels, or escalate concerns consistently.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. In 3 communal areas, windows could be opened sufficiently for a person to fall through or leave the premises, and suitable restrictors were not in place. This meant people were exposed to a foreseeable risk of falling or leaving the premises without appropriate supervision.

The provider was using unsuitable equipment to manage the risk of falls on stairwells. At 2 staircases, domestic child safety gates were being used to restrict access to which were not suitable to prevent falls in adults. One staircase was particularly steep, increasing the potential severity of injury if a person leaned against or fell over the gate. The provider also confirmed that the gates had been installed before they became involved with the service and their suitability had not subsequently been assessed. This meant the provider had not adequately assured itself that the equipment being used was suitable for the people, environment and risks present, increasing the risk of falls and serious injury.

The provider had not adequately controlled risks of burns, scalds and fire. We found exposed hot pipework in an accessible room, a radiator with a damaged cover and high surface temperature in the dining room, and an unlocked room containing an accessible hot water dispenser. People prescribed emollient creams did not have individual assessments of the associated fire risk, and their personal emergency evacuation plans (PEEPs) stated that they were not prescribed emollients. Additionally, the provider’s fire risk assessment did not consider the potential impact of the stair gates on emergency evacuation. This meant foreseeable risks relating to burns, scalds and emergency evacuation had not been fully identified or controlled.

However, the provider responded promptly to several risks identified during the inspection. Following concerns raised on 10 June 2026, window restrictors were fitted, exposed pipework was covered and access to the hot water dispenser was restricted before the second day of assessment. People told us they felt the environment was safe and equipment servicing was up to date, and equipment servicing was up to date, demonstrating that some arrangements were in place to maintain the safety of equipment and the environment. This supported people’s experience of feeling safe and demonstrated that some environmental safety measures were effective, although the risks identified showed these arrangements were not consistently effective.

The provider did not always make sure staff had the knowledge, skills and competency needed to provide safe care that met people’s individual needs. Although staffing levels were sufficient to meet people’s assessed dependency needs, the provider did not consistently ensure staff’s knowledge and competency reflected the healthcare needs of people using the service.

The provider did not ensure staff had the knowledge needed to safely meet people’s individual needs related to their medical conditions. Staff spoken with were unable to identify common signs and symptoms of stroke, and some were unable to describe appropriate seizure management. A member of staff told us, "[Person] would tell staff if [Person] was having a stroke", while another said, "From my knowledge when [person] has seizures or episodes the care plan says to lift the feet so [Person] will come back to normal." This meant staff did not consistently have the knowledge needed to recognise changes in people’s health or respond appropriately to potentially serious medical events.

The provider did not ensure staff training consistently reflected people’s assessed needs. The training matrix provided showed that 14 out of 23 staff had completed severe allergic reaction awareness training and received practical training in administering adrenaline auto-injectors. Staff had also not completed specific training in asthma and chronic obstructive pulmonary disease (COPD), despite supporting people with these conditions. Although dysphasia, epilepsy and stroke awareness training was recorded, 5 staff were unable to demonstrate the expected knowledge when spoken with. This identified a gap between recorded training completion and staff’s demonstrated knowledge and raised concerns about whether training had been effective in equipping staff to respond safely to people’s individual healthcare needs and emergencies.

The provider did not consistently maintain robust recruitment records to demonstrate that staff had been safely recruited. Records showed 2 staff members had commenced employment before all required recruitment checks had been completed. In 1 case, recruitment records did not include a full employment history, including reasons for leaving previous employment. In another case, records did not contain a completed health declaration. This meant the provider could not consistently demonstrate that all information required under Schedule 3 had been obtained and reviewed before staff commenced employment.

The provider had some arrangements in place to support staff development and ensure sufficient staffing levels. Staff received regular supervision and annual appraisals, with some competency assessments completed through themed supervision sessions. The provider’s dependency tool demonstrated that sufficient staff were deployed to meet people’s assessed needs.

Following the inspection, the home manager arranged additional training for staff. This demonstrated that the provider responded to the training gaps identified during the inspection, however we were not assured the provider had adequate measures in place to assess skills, knowledge and competency prior to our inspection.

The provider did not always assess or manage the risk of infection effectively. They did not always detect and control potential risks or demonstrate that effective systems were in place to prevent and control the spread of infection.

The provider did not consistently control infection risks in the environment. An unlocked clinical waste bin outside the service was accessible to the public. A bag of dirty laundry was stored on the floor of a shower room, and mop heads were stored in an open bucket in the basement laundry. These findings identified weaknesses in the storage and management of waste, laundry and cleaning equipment and meant foreseeable infection risks were not consistently controlled.

The provider did not have effective systems for assessing individual infection risks. The infection prevention and control (IPC) risk assessment was undated and focused on a previous outbreak affecting 3 people but did not identify the environmental risks found during inspection. The provider’s policy stated that infection risks should be assessed for each person before they started using the service and be kept under review. However, there were no personalised IPC risk assessments for people. This meant the provider could not demonstrate that infection risks specific to individuals, including those associated with their cognitive impairment or care needs, were consistently identified and managed.

The provider could not consistently demonstrate that identified IPC actions had been completed, reviewed and signed off. The laundry and linen action plan dated 21 January 2026 contained 9 identified actions that had not been signed off as completed at the time of inspection. A May 2026 audit also identified further issues without an action plan or interim risk assessment. This meant identified infection risks were not consistently followed through, monitored or reviewed to demonstrate that corrective actions had been completed and risks remained controlled.

The provider had some effective infection prevention measures in place. The service was visibly clean and tidy and people told us, “It’s clean enough” and “Oh yes, It’s clean”. We observed staff using and disposing of PPE appropriately, and suitable PPE supplies were available. Cleaning schedules and mattress checks were completed regularly, and the kitchen staff maintained records of cleaning and food safety checks. These findings provided assurance that basic cleanliness and some infection prevention practices were maintained effectively.

The provider did not always make sure that medicines and treatments were managed safely and in a way that met people’s individual needs. Staff did not always have sufficient guidance or effective systems to administer, store and account for medicines safely.

The provider did not consistently ensure medicines and treatments were stored and managed securely. On 10 June 2026, the medicines room was left unlocked with medicines, sharps, creams and food supplements accessible. We also found an expired emollient spray in use. This demonstrated weaknesses in the provider’s arrangements for securing medicines and treatments and ensuring they remained within their expiry dates, increasing the risk of inappropriate access or use.

The provider did not ensure ‘when required’ (PRN) medicines had sufficient guidance to support safe administration. Some protocols did not include key information such as maximum doses, the time between doses, potential side effects or clear instructions on when staff should seek further professional advice. One person had multiple PRN medicines prescribed, however only 1 medicine had a PRN protocol in place. This meant staff did not consistently have access to the information needed to administer all PRN medicines safely, appropriately, and in accordance to people’s individual needs.

The provider had not consistently managed controlled drugs safely. Controlled medicines (CDs) are medicines which are subject to strict legal guidelines around their use. For example, a person was prescribed controlled transdermal patches, but there was no evidence that staff signed to confirm the previous patch had been removed before a new one was applied. The provider confirmed removed patches were kept in the medicines room awaiting pharmacy collection rather than in the controlled drugs cupboard. This meant there were gaps in the systems for recording, securing and accounting for controlled medicines and the provider could not demonstrate that controlled transdermal patches were consistently subject to effective oversight.

The provider did not comprehensively manage the risks associated with a person’s severe allergies. The person had severe allergies and had been prescribed adrenaline auto-injectors. However, information relating to severe allergy management was not consistently reflected within care planning documentation and did not provide staff with readily accessible guidance regarding recognition, management and escalation of a severe allergic reaction. The provider also confirmed that the risk of visitors bringing allergens into the service had not been assessed. This meant significant and foreseeable risks had not been fully assessed or controlled, increasing the risk of avoidable harm and of a delayed or ineffective response to a severe allergic reaction.

People and relatives gave positive feedback about medicines management and communication. A person told us, "I take loads of tablets... It all seems all right." Relatives told us staff were "very good at informing us about changes in her medication" and that they were told "day or night about changes to her medication." Another relative said, "I don't have any concerns about her medication." This demonstrated that people and relatives generally felt informed and confident about the medicines provided to them.