CQC report explained · a nursing home
What the CQC found at Croft House Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, June 2023
Rated Good; inspectors found safe, caring care and stronger management after the previous Requires Improvement rating.
This was an unannounced follow-up inspection on 9 May 2023. Two inspectors and an Expert by Experience spoke with people living in the home, relatives, staff and managers. They also checked care plans, recruitment records, audits and other records.
The home was rated Good overall. Safe and Well-led were both rated Good, improving from Requires Improvement at the last inspection. Inspectors found enough staff, safe recruitment, suitable safeguarding arrangements and systems for managing medicines, risks and infection.
Inspectors also found person-centred care, caring staff and activities suited to people's interests. Management checks and feedback systems were in place. The report notes that there was no registered manager in post at the time, although a manager had applied to register.
Enough staff
Inspectors found staffing levels met people's needs. Recruitment checks were also completed safely.
“There were enough staff on duty to meet people's needs and to provide appropriate care and support.” from the report
Person-centred care
Care plans included people's preferences. Staff supported people with choices about food, drinks and activities.
“Care plans were well written and contained information about people's likes and dislikes.” from the report
Strong oversight
The home had regular checks, audits and reviews. Managers used feedback and identified actions for improvement.
“There was a robust system of checks, audits and reviews that supported a culture of continuous learning and improvement across the service.” from the report
Activities and engagement
People were offered different activities, including games, cooking, sensory sessions and trips out.
“The activities co-ordinators provided a range of different engagement opportunities including games, cooking sessions and trips out.” from the report
Manager registration
minorThere was no registered manager in post during the inspection. A manager had applied to register, but the application was still being assessed.
“At the time of our inspection there was not a registered manager in post.” from the report
Bathroom refurbishment
minorTwo bathrooms had been identified as needing refurbishment within six months. Families should ask whether this work has now been completed.
“The service had identified 2 bathrooms that needed refurbishment within 6 months and this was recorded in their home improvement plan.” from the report
- 01Has the manager's application to register now been approved, and who is responsible for the home while it is being assessed?
- 02Have the two bathrooms identified for refurbishment been completed, and if not, when will the work finish?
- 03How do you check that staffing levels remain sufficient on every floor, including the dementia and nursing floors?
- 04What actions came from the latest resident, relative and staff surveys, and what progress has been made?
- 05How are families told about accidents, incidents or other problems affecting their relative?
This was an unannounced follow-up inspection focused on Safe and Well-led; Effective, Caring and Responsive were not rated in this report. This explanation was written from the published report of 16 June 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, July 2022
Rated Requires Improvement; inspectors found clear improvements after an Inadequate rating, but staffing, safety details and leadership still need close watching.
This was an unannounced follow-up inspection on 26 May 2022. Inspectors spoke with people living in the home, relatives, staff and a visiting health professional. They reviewed care, medicines, recruitment and management records.
The home had improved since the previous inspection. Risks were being discussed and recorded more clearly. Staffing levels were based on people's needs, medicines were generally managed safely, and infection control had improved. People mostly said they felt safe and staff responded reasonably quickly.
Some problems remained. Two people at high risk of falls wore loose slippers. Staff had limited time for interactions, some agency staff were less familiar with people's needs, and one relative reported incorrect application of a cream. The home also had no registered manager in post at the inspection.
The overall rating changed from Inadequate to Requires Improvement. The home was no longer in breach of the regulations identified at the previous inspection and was taken out of Special Measures. CQC said the home still needed to show that improvements could be sustained.
Improved risk management
Individual risks were recorded with plans for safe support. Senior staff discussed risks daily and followed up actions.
“Records showed risks were assessed, monitored and reviewed.” from the report
Medicines mostly managed safely
Medicines were stored, recorded and administered safely in most cases. Staff were receiving refresher training and competency checks.
“Medicines were safely stored, recorded and managed. Staff checked if people needed any pain relief and supported them appropriately with this.” from the report
Cleaner and better infection control
The home was clean and tidy, with suitable supplies of protective equipment and COVID-19 testing in place.
“The premises were found to be clean and tidy. Issues found at the last inspection had been resolved.” from the report
Positive relationships
Inspectors saw positive interactions between people and staff. People, relatives and staff gave largely positive feedback about the care and the openness of the culture.
“We observed positive interactions between people and staff which showed the staff team working well together to support people.” from the report
Learning from incidents
The provider reviewed incidents, looked for causes and shared learning with staff. It had also taken action to reduce falls.
“Incidents which occurred were looked into to understand the root cause and learning was taken from these events.” from the report
Falls hazards
seriousTwo people at high risk of falls were seen wearing loose slippers. Inspectors also found an environmental trip hazard, which the provider addressed after the inspection.
“Two people who were at high risk of falls, were seen to be wearing loose fitting slippers, posing a falls hazard.” from the report
Limited staff time
needs fixingThere were enough staff according to the dependency tool, but staff had limited time to interact with people. One person did not feel reassured by the number of staff visible.
“There were sufficient staff to meet people's needs, although staff were limited in the time they had available for interactions with people.” from the report
Agency staff familiarity
needs fixingAn agency nurse was not familiar enough with a person's needs to attend a meeting with a visiting professional. The provider said it was planning extra support and using regular agency workers.
“An agency nurse was unable to attend a meeting with a visiting professional as they were not sufficiently familiar with a person's needs.” from the report
Cream applied incorrectly
seriousA relative said agency nurses had twice tried to apply a cream to the wrong person. This was linked to two people having the same first name.
“A relative told us that agency nurses had tried to apply a cream to their loved one incorrectly on two occasions.” from the report
Management stability
needs fixingThe home had experienced several changes in the manager role. A new home manager had just started, and the provider still needed to show that improvements would last.
“The provider will need to demonstrate sustainability in this key question before we are able to rate this as good.” from the report
- 01How is the new home manager progressing with registration, and who is responsible for the home until that is complete?
- 02How do you check that people at risk of falls have suitable footwear and that hazards are removed promptly?
- 03What checks are made to ensure agency staff know each person's needs before giving care or attending appointments?
- 04How do you prevent medicines and creams being given to the wrong person, especially where people have the same first name?
- 05How are people and relatives now involved in care planning and regular service meetings?
This was an unannounced follow-up inspection focused on Safe and Well-led; the report does not give ratings for Effective, Caring or Responsive. This explanation was written from the published report of 6 July 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Croft House Care Home
7 rated inspections over 7 years: the service has improved, from Inadequate to Good.
- June 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2022Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- November 2021Inadequatestayed InadequateSafe: InadequateWell-led: Inadequate
- February 2021Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- October 2017Goodup from Requires improvementSafe: GoodWell-led: Good
- October 2016Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2016InadequateSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- January 2015
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- September 2011
Registered with the Care Quality Commission on 30 September 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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