Little Croft Care 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 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The managers and staff ensured the service put people first and focused on their needs, wishes and aspirations. Some staff raised concerns around the team dynamics. At times they felt uneasy about other staff member’s behaviour. We gave feedback to the provider about this. They reassured us they were aware of this and had already taken action.

Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. A new manager had been appointed since the last inspection who was in the process of registering with the CQC. The manager had worked at the service for several years prior as the deputy. A new deputy was in post and the previous registered manager, continued to support the service to deliver training. They also helped in a management capacity to support with covering leave. The manager demonstrated openness and integrity. They believed in leading the staff by example. They told us they had an open-door policy and encouraged the staff and people with openness.

Overall, the staff found the management team supportive. One staff member told us, “I like the approach of the managers. They are supportive and encourage me.” Another staff member told us, “I have seen positive changes at the home. The managers are caring and want the best for people and the staff.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they were able to speak to the management team about any concerns and had access to whistleblowing information and guidance if required. The provider focused on engaging with people and relatives to support people to achieve good overall outcomes. Staff and resident meetings were held regularly This provided an opportunity for people to speak up with any suggestions or concerns. Staff supervisions were carried out regularly and were a means of support for the staff. One staff member told us, “I have supervision, and they are supportive. I have spoken up in the past and I was reassured and supported.”

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 ensure equality in their recruitment and training opportunities. Reasonable adjustments were in place where appropriate. The staff were able to request additional support if required to fulfil their role.

At the last inspection we were not satisfied with the quality assurance monitoring systems in place. Improvements were required to some audits to ensure they were more robust and effective. The provider carried out regular visits to the service, however no formal audits were taking place by the provider, to evidence how they were monitoring the service. The provider had carried out a staff survey, however the overall results had not been analysed, shared with staff and an action plan put into place. Improvements were also needed to the recording of some care documentation.

At this assessment, we found improvements had been made. The provider visited the service and carried out audits. This focused on, for example, medicines, care records, environment, staffing levels, recruitment and reviewing the manager’s audits. Action plans were in place, where shortfalls were identified. This was shared with the manager to take action. The service carried out surveys with people and staff. Since the last inspection the staff survey had been analysed, and an action plan was in place to address any shortfalls. People’s care records were being audited daily by the deputy. The deputy told us, since they had been in post, they had been reviewing people’s care records to make them even more person centred. They reviewed the daily entries made by the staff team and identified any gaps and discrepancies. They shared any learning with the staff team. The provider and manager also carried out audits of people’s care records.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The service worked closely with health professionals. This included the local GP who carried out weekly ward rounds. The manager told us they had a supportive relationship with the GP surgery. They valued the input and advice. The service also worked closely with the district nursing team who visited some people at the service.

The service had links with the local church, who visited the service monthly to hold an inhouse service for people. The manager planned to build on links with the local community, for example inviting the local schools to visit the people in the home. Some links had been lost since the COVID pandemic.

The manager focused on continuous learning and improvement within the service and shared ideas and learning. They encouraged staff to think creatively about how to improve people’s quality of life and support them to enjoy a full and active life. Where areas of improvement were identified, the provider responded promptly and positively. Within the service was a ‘you said, we did’ board. People were able to make suggestions about the improvements they wanted to see. One person had commented, they wished for new garden furniture or the current furniture to be fixed and painted. This had been responded to. Plans were in place with maintenance being carried out of the furniture.