Croft Manor Residential 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 at the service. Governance and quality assurance systems were not sufficiently robust to identify, act on and monitor risks and shortfalls, and leaders did not consistently have effective oversight of the quality and safety of care being provided.

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 and culture focused on person-centred care, dignity, respect and the needs of people using the service. Staff understood the provider’s values and described a shared focus on improving people’s experiences and care.

Staff understood the provider’s values and described a shared focus on delivering person-centred care. One staff member identified the values as “Respect, dignity, privacy and person-centred care.” Staff also told us that, despite previous changes in management and instability, they felt the service was now in a good place, with staff working towards the same goals and making progress. This demonstrated that staff understood the values underpinning the service and experienced a stronger sense of shared direction.

The provider’s statement of purpose was detailed and reflected the service’s vision. This provided a clear framework for the service’s aims and the care it intended to provide and supported a consistent understanding of the provider’s approach to people’s care and support.

People and relatives also described a positive culture despite the changes the service had experienced. One relative told us, “They kept us up to date with who was in charge.” This demonstrated that the provider communicated changes in leadership with relatives and supported people and those close to them to remain informed about the service.

Leaders did not always have the knowledge and oversight required to consistently fulfil their legal, regulatory and governance responsibilities. However, people, relatives and staff described the home manager as approachable, supportive and committed to improving the service.

Leaders did not consistently demonstrate the knowledge required to meet their legal and regulatory responsibilities. Leaders were unable to demonstrate how decision-specific capacity assessments and best interest processes had been applied and recorded consistently in relation to restrictive care arrangements reviewed during the assessment. When we asked how the service assessed people’s capacity where restrictive practices had been implemented, modified diets and locked facilities, the manager was unable to explain the process used to assess and record capacity in relation to such restrictions. This demonstrated a lack of understanding of the MCA and the requirements associated with assessing and recording people's capacity where restrictions may be imposed.

However, people, relatives and staff gave positive feedback about the home manager and their approach to people and the workforce. People told us, “Management look after us well” and “Yes. She's lovely.” A relative described the manager as “lovely”, while another said, “They are brilliant. They are more than approachable.” Staff told us, “The home manager is really good with people and she has really positive attitude to team building. She really turned this place around,” and “They [management] support us with everything.” This demonstrated that the home manager was approachable, valued by people, relatives and staff, and had contributed positively to team relationships and the service’s culture. The provider had also taken steps to support management development by enrolling managers on MCA and best interests training.

The provider fostered an open and positive culture where people, relatives and staff felt able to speak up, raise concerns and share their views.

Staff told us they felt able to raise concerns without fear of reprisal and that managers responded appropriately. Staff also told us they could share ideas, make complaints and escalate concerns, which they described as being handled professionally and in a timely way. This demonstrated that staff felt listened to and confident that they could raise concerns without fear of negative consequences.

The provider had arrangements to support staff to speak up. Up-to-date whistleblowing policies were accessible to staff, and staff understood how to use these if needed. This provided clear routes for staff to raise and escalate concerns.

People and relatives also knew who they could approach if they wanted to raise a concern or share their views. People told us they would speak to “the office manager”, “the boss lady”, “one of the carers” or “anyone here”. Relatives similarly told us they would speak to the manager or deputy manager. This demonstrated that people and those important to them felt able to raise concerns and had confidence that their views would be heard.

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.

The provider had policies in place to promote equality, diversity and inclusion and protect staff from discrimination and harassment. These provided clear expectations for staff and supported a respectful and inclusive working environment.

The provider considered individual staff needs and made reasonable adjustments where required, including for staff with health-related conditions. This supported staff to remain in work and carry out their roles safely and effectively, demonstrating that individual circumstances were considered and appropriate support was provided.

Staff feedback reflected a positive workplace culture, with staff describing feeling valued and supported. This demonstrated that the provider’s approach to equality, diversity and inclusion was reflected in staff experience.

A healthcare professional also told us, “I find all staff members open, hardworking, honest, empowering and adaptable to all situations they may face. They seem to be an inclusive team.” This further supported evidence of an inclusive and respectful culture within the service.

The provider did not have effective systems of governance, management and oversight to identify, monitor and address risks and drive sustained improvement. The provider’s audit and quality assurance processes were not sufficiently robust to identify significant shortfalls, and where concerns were identified, there was insufficient evidence that actions were appropriately planned, completed and monitored.

Although the provider’s audits and quality assurance processes identified some concerns, they did not consistently identify the full range of issues found during inspection or demonstrate that identified actions had been completed, reviewed and sustained. A range of audits and monitoring tools were in place, including audits relating to safeguarding, infection prevention and control, medicines, care records, the environment and other areas of service delivery. However, these had not identified significant risks and inconsistencies subsequently found during our inspection. This meant the provider’s own quality monitoring processes were not providing effective assurance about the safety and quality of care being delivered.

The provider submitted a quality assurance report dated 12 May 2026, completed by the nominated individual. This was the first formal quality assurance report by the nominated individual since their appointment in 2023. The quality assurance report identified some areas requiring improvement that we found on inspection, including the need for minimum and maximum temperature recording for fridges and room thermometers, 90% completion of fluid charts for 3 people, the need for accident and incident trend analysis, and concerns regarding the clinical waste bin being checked and secured. The provider had identified a planned 3-monthly follow-up process, however, despite identifying these shortfalls, the report did not include a clear action plan, responsible person, completion date or evidence of subsequent review and sign-off. Not all concerns we found on inspection had been identified through this review. This meant this process was not sufficiently robust to ensure compliance with the regulations, or that identified concerns would be addressed in a timely way.

Audits identified issues relating to safeguarding and infection prevention and control, but action plans did not consistently demonstrate clear ownership, timescales, outcomes or sign-off. In some areas, subsequent audits identified further concerns without demonstrating that previous actions had been completed or that learning had been embedded. This demonstrated that the provider’s governance systems did not consistently operate to ensure the quality and safety of the service was assessed and improved - identifying a concern, assessing the risk, taking action, checking the outcome and confirming sustained improvement.

The provider recognised the need to strengthen its oversight and had engaged external auditors to undertake an infection prevention and control (IPC) audit and a care plan audit. This demonstrated that the provider had taken some steps to strengthen its quality assurance arrangements; however, at the time of our assessment, these arrangements had not yet been sufficiently embedded to demonstrate that risks were consistently identified, addressed and monitored through to sustained improvement.

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.

Staff told us they worked well with a range of healthcare professionals to ensure people’s needs were met. The nominated individual confirmed there were positive working relationships with external professionals, including the GP and District Nursing Team. This supported coordinated care planning and enabled staff to seek appropriate professional input when people’s needs changed.

The provider had systems in place to support regular communication and review of people’s needs with external professionals. This helped ensure care remained appropriate to support people’s health and wellbeing.

Healthcare professionals provided positive feedback about the service. A healthcare professional told us, “As a team we have found that they will engage in training that we offer and will reach out if they require support. They are proactive in accessing professional input where required.” This demonstrated that the provider was receptive to professional advice, engaged with external support and sought to develop staff knowledge and practice.

The provider had undertaken improvement activity and demonstrated a commitment to learning; however, learning and improvement were not yet consistently embedded through effective assurance, review and sustainability processes across the service.

Inspection findings showed that learning and improvement processes were not always effective. Audits and action plans were not consistently followed through to completion or signed off, and recurring issues were not always identified, monitored or embedded into practice. This included concerns relating to safeguarding, infection prevention and control, risk management, medicines management, care planning and clinical monitoring. These findings demonstrated that opportunities to learn from identified shortfalls were not consistently translated into sustained improvements.

However, there was evidence that the provider had made improvements in some areas. A healthcare professional who had visited the home consistently over the previous year told us, “I have noticed a significant improvement in the overall cleanliness and presentation of the environment.” This demonstrated that improvements were visible to external professionals and had positively affected the service environment.

Staff described being involved in discussions about improvements and said managers actively sought their views. A staff member told us, “Yes, they [managers] sit down with us and ask what do you think. They always sit down in handover and ask about improvements.” This demonstrated that staff were encouraged to contribute ideas and were involved in identifying areas for improvement.

Staff also described a positive change in management visibility and support. One staff member told us that previously managers had not been involved in care delivery or handovers and staff had felt uncertain about whether they were doing things correctly. They told us that since the new manager, “they have taught us everything, really feel confident in what we do. Nothing that I'm concerned about.” This demonstrated that management involvement and staff support had improved confidence and contributed to a more open learning culture.

Overall, while there was evidence of positive progress, greater management visibility and increased staff involvement, the provider needed to strengthen its governance arrangements to ensure learning from identified concerns was consistently embedded and resulted in sustained improvement across the service.