Little Croft Care 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 requires improvement (July 2023). At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 proactive and positive culture of safety, based on openness and honesty. The manager listened to concerns about people’s safety, investigated and reported any incidents or concerns. Good practice was embedded with any lessons learnt, communicated to staff and reported appropriately. Actions were taken following accidents and incidents with consideration as to why these may have occurred and what may be done to reduce repeat events. A monthly analysis of falls and incidents was recorded. This contained information about the number of falls people had that month and any known causes. This included for example where people had an infection or had been unwell.

The staff told us feedback was given in staff meeting and handovers regarding lessons learnt. One staff member told us, “We are made aware of learning from falls and any actions taken. This included when sensor mats have been put in place and referrals made to professionals.”

The provider had a proactive and positive culture of safety, based on openness and honesty. The manager listened to concerns about people’s safety, investigated and reported any incidents or concerns. Good practice was embedded with any lessons learnt, communicated to staff and reported appropriately. Actions were taken following accidents and incidents with consideration as to why these may have occurred and what may be done to reduce repeat events. A monthly analysis of falls and incidents was recorded. This contained information about the number of falls people had that month and any known causes. This included for example where people had an infection or had been unwell.

The staff told us feedback was given in staff meeting and handovers regarding lessons learnt. One staff member told us, “We are made aware of learning from falls and any actions taken. This included when sensor mats have been put in place and referrals made to professionals.”

The staff at the service worked with people and healthcare partners to establish and maintain safe systems of care. The staff and managers ensured there was continuity of care, from admission to the service. Assessments of people’s needs were undertaken prior to admission. This was to ensure the service could meet the person’s needs and the appropriate referrals were made. This included for example referrals to the district nurses and registering people with a local GP. Where people’s needs had changed or input was required from other professionals, the appropriate referrals were made.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The staff’s focus was improving people’s lives, while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The staff understood their responsibilities to report any safeguarding concerns. The management team had taken appropriate action where necessary in response to safeguarding concerns. A log of the safeguarding referrals made, were maintained by the service. This included the reason for the referral and information about how this was investigated.

Staff had a good understanding of safeguarding, and they had received the appropriate training. One staff member told us, “I have no concerns, and I would speak to my manager if I did. I feel people receive good care here.”

The provider worked with people to understand and manage risks. On preadmission to the service, the management team carried out an assessment of people’s needs. This helped to form risk assessments, which were put into place. Staff provided care to meet people’s needs that was safe and supportive. They enabled people by promoting independence with day-to-day risks managed. For example, where people were at risk of falls, sensor mats were used to alert staff of movement in the person’s room.

Risk assessments were in place, detailed and regularly reviewed. Changes to people’s needs were noted and assessments updated. The deputy manager told us they had been reviewing people’s care records and risk assessments regularly. This included when people had returned from hospital, or any risks had increased.

We observed that some ferrules on people’s Zimmer frames needed replacing. We gave feedback to the manager about this, and they planned to take action. One downstairs small window had a window restrictor which was faulty. We reported this to the manager and prompt action was taken to repair this, the same day.

The environment of the service had been maintained. Since the last inspection of the service, many areas of the building had been decorated. This included the lounges, which had new seating. Some corridors had been decorated and bedrooms, with new flooring. An ongoing plan to maintain the environment was in place, with plans to paint the front of the house in the coming weeks. Regular checks of the physical environment and of equipment were undertaken, to minimise the potential for harm. Equipment was serviced and checks were undertaken of electrical items, moving and handling and fire safety equipment to ensure that it was safe to use. Personal emergency evacuation plans (PEEPS) outlined the levels of support people required in the event of an emergency. Regular fire safety checks and evacuation tests were carried out.

At the last inspection we could not be satisfied the systems in place ensured safe levels of staffing during the night. We identified shortfalls, where on 11 occasions in a one-month period, 2 staff worked instead of 3. Staffing levels during the night had not considered emergencies. The number of staff on duty to respond in these situations was not safe. At this assessment, we found improvements had been made with no shortfalls identified. The manager told us 3 staff always worked during the night. The staff and the management team helped to cover any shortfalls. The manager told us they were recently called by the night staff team as 1 of the staff members felt unwell. The manager worked the shift, to avoid any shortfalls and to keep people safe.

We observed people being attended to quickly by staff and call bells were answered promptly. People's needs were assessed regularly and the provider adjusted staffing levels to ensure people's needs could be met. The manager told us the service was currently working at a much lower occupancy of people. On some occasions the staffing levels on a morning shift were lowered by 1 staff member. This was kept under continuous review.

Overall, the staff felt the staffing levels were safe at the service. Some staff felt that some people’s dependency was too high for the service and more staff were needed. We spoke to the manager about this, and they explained, they were working with a lower occupancy and up until recently the service had 10 vacant beds. Other staff felt that staffing levels were manageable, and they acknowledged the lower occupancy. We did not identify any shortfalls with staffing levels, but we have asked the manager to keep this under review.

The provider followed safe recruitment practices to ensure only suitable persons were employed to support people. People were supported by staff who completed training specific to those they supported. This included for example training in relation to dementia and behaviours that challenge.

The provider assessed and managed the risk of infection, with measures in place to reduce the risk of cross contamination. The service was clean and well maintained. Regular checks and audits were completed to ensure staff followed the provider’s infection prevention and control (IPC) policies, to help keep people safe and the service clean. Personal protective equipment (PPE) was available, we observed staff used and disposed of PPE and soiled linen appropriately. Hand hygiene stations were well-maintained and correct waste management procedures were observed.

At the last inspection we observed medicines were not stored securely, with 2 medicines trolleys left in the dining room and not double locked. We found some medicines administration records were not up to date and accurate. People's prescribed medicines were not being signed into the service correctly by staff. This included keeping a tally of the overall stock and balance. Entries were also not double signed when medicines records were handwritten.

At this assessment, we found the necessary improvements had been made. The medicines trolleys were double locked away when not in use and stored securely. We reviewed a sample of medicines administration records. Each record had been signed by the staff when medicines had been administered. If a medicine had not been given, then a code was clearly recorded. Where medicines had been stopped by a GP, the manager asked the GP to record this on the medicines chart with a signature and date. Any handwritten medicines charts were double signed by the staff.

The manager had recently introduced a list of medicines for each person. This contained information about the name of each medicine and what each medicine was prescribed for. The manager told us, this had helped people to understand the reason why medicines were prescribed. The staff were able to explain, using the list as a guide.

A clear audit trail was maintained of the stock entering the building, with medicines signed in by 2 staff. When medicines were discontinued this was safely disposed of and returned to the pharmacy, with records maintained.