CQC report explained · a residential care home
What the CQC found at Croft House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Inspectors were assured about most infection-control arrangements, including PPE, testing, hygiene, visitors and the management of outbreaks. They were only somewhat assured about safe isolation and social distancing because care plans and risk assessments were missing.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, April 2022
Inspected but not rated; inspectors found good COVID-19 infection controls but gaps in isolation and mental-capacity records.
This was an announced, targeted inspection on 16 February 2022. It focused on infection prevention and control during COVID-19 outbreaks, and on whether staffing pressures affected people.
Inspectors were assured about visitors, testing, personal protective equipment, hygiene, social distancing arrangements and infection-control policies. Relatives could visit, although visits were briefly paused during an outbreak and contact was maintained by telephone and video calls.
There were gaps in records and assessments. People did not have care plans and risk assessments explaining how staff should support safe isolation or social distancing. Mental capacity assessments were not always in place for COVID-19 decisions.
The home was inspected but not rated. This means the report does not give a Good, Requires improvement or Inadequate rating, and it is not a full assessment of all aspects of care.
Protective equipment
Staff were seen using PPE when supporting people and moving around the home, in line with government guidance.
“Staff were observed wearing personal protective equipment (PPE) when supporting people and moving around the service in accordance with government guidance.” from the report
Infection controls
Inspectors were assured that the home had arrangements for preventing and managing infections, including testing, hygiene and an up-to-date policy.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Family visits
Relatives were able to visit under safety measures. During a brief outbreak pause, people were supported to stay in touch by phone and video.
“People's relatives were able to visit the service. Measures were in place to ensure visits took place in accordance with government guidelines.” from the report
Isolation plans
needs fixingCare plans and risk assessments did not explain how staff should support people to isolate or socially distance safely when appropriate.
“People did not have care plans and risk assessments in place to advise staff about how to safely support people to isolate or socially distance when it was safe and practical to do so.” from the report
Mental capacity records
needs fixingMental capacity assessments were not always available to support best-interest decisions about COVID-19 care.
“Mental capacity assessments were not always in place to support decisions made in people's best interest.” from the report
- 01What care plans and risk assessments are now in place for safely supporting someone to isolate or socially distance?
- 02How do you record mental capacity assessments and best-interest decisions about COVID-19 care?
- 03What measures are currently used to manage COVID-19-related staffing pressures?
- 04How would visits be arranged during an infection outbreak, and how would residents stay in contact with family if visits were paused?
This was a targeted inspection of infection prevention and control, with questions about staffing pressures; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 7 April 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.
What inspectors found, March 2021
Inspected but not rated; inspectors found safe, caring support and well-managed infection control, but identified some risk-record and staffing issues.
This was an unannounced targeted inspection on 23 February 2021. Inspectors checked infection prevention and control, staffing, risk management and safeguarding. They spoke with staff and managers, reviewed records and contacted four relatives. They could not ask residents directly about their care because of their communication needs.
Inspectors found people were protected from abuse and avoidable harm. Staff knew people well, supported their choices and independence, and treated them with dignity. Staffing was considered safe, although bank and agency staff were being used and recruitment was continuing.
Infection control was well managed. The home had supplies of protective equipment, regular COVID-19 testing, visitor controls and increased cleaning. A COVID-19 outbreak in November 2020 was contained using zoning and staff grouping.
This was a targeted inspection, so the service was not given a new overall rating. The previous overall rating was Good, published in April 2018. The Safe question was previously Requires Improvement and was not re-rated because only specific parts were checked.
Caring, individual support
Staff knew people's routines and preferences and supported their choice, control, independence, dignity and human rights.
“People received individual person centred support that promoted and maximised their choice, control and independence in how they lived their lives.” from the report
Good infection control
The home had updated COVID-19 plans, enough protective equipment, regular testing and visitor controls. It also increased cleaning of frequently touched areas.
“The infection prevention and control practice of managing the current COVID-19 pandemic was found to be well managed.” from the report
Safeguarding
Staff understood their safeguarding duties. Incidents and allegations were investigated, reviewed and shared with relevant organisations where needed.
“People were protected from avoidable harm and abuse.” from the report
Safe staffing at the visit
Inspectors found staffing met people's assessed needs and safety. Shortfalls were covered by bank staff, agency staff or the management team.
“Staff deployment met people's individual assessed needs and safety.” from the report
Some risk records lacked detail
needs fixingOne plan about physical intervention and one about community drives in the service vehicle were not detailed enough. The manager amended them during the inspection.
“One person's risk plan associated with physical intervention and risks associated with community drives in the services vehicle could have been more detailed” from the report
Contractor risks needed a service-specific plan
needs fixingBuilding work was taking place and the risk assessment for contractors was generic rather than specific to the home. Two incidents involved contractors not securing the environment, although no one was harmed.
“From reviewing incident records, we saw two incidents caused by contractors not securing the environment.” from the report
Agency staff and staffing continuity
minorRelatives were less positive about agency staff because they could be unfamiliar and less consistent. Recruitment was continuing, and inspectors reminded managers to maintain assessed staffing levels at all times.
“Relatives were less positive about agency staff being used due to the unfamiliarity and lack of consistency and continuity.” from the report
- 01How do you make sure risk plans remain detailed and up to date, especially for physical intervention and community drives?
- 02What service-specific risk assessment is now used for contractors and building work?
- 03How do you maintain the assessed staffing levels when staff are absent?
- 04How much agency staff is currently being used, and how do you ensure they know each person's needs and routines?
- 05How were lessons from the November 2020 COVID-19 outbreak used to improve infection control?
This was an unannounced targeted inspection of specific parts of Safe, including infection control, staffing, risk management and safeguarding; the other key questions were not assessed and the previous ratings carried over. This explanation was written from the published report of 17 March 2021 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
3 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- April 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- March 2021Inspected but not ratedSafe: Inspected but not rated
- April 2018Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2014
Registered with the Care Quality Commission on 30 June 2014.
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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