We carried out a review of the data available to us about Croft Dene Care Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Croft Dene Care Home, you can give feedback on this service.
Croft Dene Care Home is a care home providing accommodation and nursing or personal care for up to 43 people. Accommodation is provided over two floors. The environment had been adapted to meet the needs of people. At the time of our inspection 37 people were resident at the home.
People’s experience of using this service and what we found
The service was well-led. Action had been taken following the last inspection to ensure legal requirements were met and service improvements were made. Governance systems were effective in monitoring quality at the home. The registered manager worked in an open and transparent way and understood their responsibilities in relation to the duty of candour regulation.
Policies and procedures in relation to infection prevention and control (IPC) to prevent the spread of infections were in place. Arrangements were in place to support people to maintain contact with people important to them. This included indoor visits from relatives or friends and supporting people to maintain contact with the use of technology such as telephone calls.
Medicines were managed safely and reviews of incidents took place to assess if any improvements to staff practice could be made. Safe recruitment procedures had been followed and there were enough staff deployed to meet people’s needs. Systems were in place to safeguard people from the risk of abuse and the risks people were exposed to had been assessed.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
People’s communication needs were met. Information was available to people in alternative formats to support their communication needs. End of life care plans were in place to ensure any wishes people had for their end-of-life care were recorded. Staff provided care and support which was person-centred to the individual needs of people. Systems were in place to investigate and respond to any complaints and to acknowledge any compliments.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 23 June 2022) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
This inspection was carried out to follow up on action we told the provider to take at the last inspection.
We carried out an unannounced focused inspection of this service on 17 and 22 March 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, good governance, duty of candour and fit and proper persons employed.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions safe, responsive and well-led which contain those requirements.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Croft Dene Care Home on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
Croft dene Care Home is a care home providing accommodation and nursing or personal care for up to 43 people. Accommodation is provided over two floors. The environment had been adapted to meet the needs of people. At the time of our inspection 42 people were resident at the home.
People’s experience of using this service and what we found
A system to ensure regulatory requirements were met was not fully in place. We identified shortfalls in areas of the service including the assessment of risk, infection control, recruitment of staff and governance. Duty of candour policies and procedures had not been followed. The location's service user bands were not reflective of the support needs of some people. We have made a recommendation about this.
Staff were not always recruited safely and safe infection control procedures were not always followed. A range of risk assessments were in place to help ensure the safety of people and the environment. However, all the risks people were exposed to had not been assessed.
Systems were in place to safeguard people from abuse and there were enough staff deployed to meet people’s needs. Staff responded to people quickly and displayed kind and caring attitudes towards people during their interactions. Medicines were managed safely and accidents and incidents were well managed.
Care plans varied in the amount of detail they contained and end of life care wishes had not always been discussed with people. We have made a recommendation about this. People and most relatives were complimentary about staff and of the care provided. One relative told us, “Croftdene has the most extradentary group of staff throughout all departments.” The home did not have an activity co-ordinator employed at the time of the inspection. This had impacted on people’s social needs being met. We have made a recommendation about this.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 19 May 2020).
Why we inspected
We received concerns in relation to safety, a lack of person-centred care and the overall governance of the service. As a result, we undertook a focused inspection to review the key questions of safe, responsive and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
We have found evidence that the provider needs to make improvements. Please see the safe, responsive and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.
We have identified breaches in relation to the recruitment of staff, safe care and treatment and overall governance at the service. Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.
We found the following examples of good practice.
The service had in place appropriate systems for regular testing of both staff and people living at the home.
Appropriate processes were in place to facilitate people having visitors at the home in line with the current government guidance.
There was a good supply of PPE available at the home.
The provider had put in place a range of policies and processes to support safe care and facilitate visiting to the home.
Further information is in the detailed findings below.
Croftdene Care Home provides care and accommodation for up to 42 people with nursing care needs and people who are living with dementia. At the time of the inspection the service supported 36 people.
People’s experience of using this service and what we found
People felt safe and secure living in the service. People and their relatives were happy with the support provided and had good relationships with staff.
Staff safeguarded people from abuse and risks to people’s health, safety and wellbeing were assessed and managed. There were enough staff to meet people’s needs and safe recruitment procedures were followed. Medicines were administered and managed safely. The provider learned from previous accidents and incidents to reduce future risks. The premises were well maintained, clean and tidy.
Assessments of people’s needs were completed before they moved into Croftdene Care Home to ensure staff could effectively support them. Staff felt supported in their roles and received regular training, supervisions and annual appraisals. People were supported to enjoy a balanced diet and to access health care services to maintain their health. People were supported to have maximum choice and control of their lives, and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.
People were well looked after, respected and supported in a dignified manner. Staff promoted people’s independence by encouraging them to care for themselves, where possible. People’s personal information was kept secure and they were supported to access advocacy services, when needed.
People received person-centred care and their preferences were reflected in their care plans. Staff knew how to communicate with people effectively and information was provided to people in ways they would understand. People and relatives had no complaints about the service but knew how to raise concerns. The provider had a complaints procedure in place and all complaints received were investigated and actioned. People’s social needs were met and a wide range of activities were organised for people to enjoy both inside the service and in the local community.
The service was well-managed. People and relatives spoke highly of the staff and care provided. Management operated an open-door policy and were approachable to all. An effective quality assurance process was in place. People and relatives were regularly consulted about the quality of the care via meetings and surveys. Staff were involved in the ongoing development and improvement of the service through regular meetings.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk.
Rating at last inspection
This was our first rating of this service since a new provider (Crystal Croftdene Limited) took over in April 2018. There was an inspection on 19 February 2019 however, the report following that inspection was withdrawn as there was an issue with some of the information that we gathered.
Why we inspected
This is a planned re-inspection because of the issue highlighted above.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
People's experience of using this service: The service was safe. The risks which people faced in their daily lives were reduced as much as possible. Staff recognised the signs of abuse or harm and they reported their concerns in line with correct safeguarding policies and procedures.
Medicines were well managed and the home was clean and tidy.
People had achieved positive outcomes through good partnership working between staff and external professionals. Appropriate staff training and supervision ensured people were supported by staff who were competent in their role.
People were supported to have maximum choice and control of their lives and were supported in the least restrictive way possible. Staff encouraged people to maintain or regain independence.
People were well cared by staff who knew people very well. Staff treated people with kindness, patience, dignity and respect.
The service was responsive and support could be adapted to meet people's needs and wishes without difficulty.
Staff supported people to participate in a range of activities and to maintain community links. This provided people with the opportunity for social interaction.
The leadership, management and governance of the service ensured the delivery of good quality, person-centred care. The management team strived to achieve high standards through continuous improvement. The quality and safety of the service was closely monitored through regular checks and audits.
Rating at last inspection: This was our first inspection of this service since a new provider (Crystal Croftdene Limited) took over in April 2018.
Why we inspected: This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received.
Follow up: We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Further inspections will be planned for future dates in line with our inspection programme.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk