CQC report explained · a residential care home
What the CQC found at Croft Manor Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe, there were enough staff, and medicines were administered safely. Some skin integrity risks were not fully assessed, although staff understood how to reduce those risks and the home had started using a recognised assessment tool.
- Effective?
- Good
- Staff were trained and supported, and worked with health professionals. The home met people’s dietary needs, but people living with dementia were not always given a meaningful reminder of their meal choice before lunch.
- Caring?
- Good
- Inspectors saw staff treating people with kindness, dignity and respect. Staff knew people’s preferences and supported their independence and involvement in care decisions.
- Responsive?
- Good
- Staff knew people well and generally provided personalised care. Some care records were inaccurate or missing important details, and end-of-life plans needed more information about people’s preferences.
- Well-led?
- Requires improvement
- People and staff spoke positively about the manager, but oversight was not always effective. Improvement plans did not include all the concerns found, or clearly explain how and when they would be fixed.
What inspectors found, May 2020
Rated Good overall; inspectors found kind, safe care, but the home’s leadership and improvement records still needed work.
This was an unannounced inspection on 25 February 2020. Inspectors spoke with people, relatives and staff, observed care, and checked care plans, medicines, recruitment files and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. People were seen as safe and supported by enough staff. Medicines were managed safely, staff were trained, and people were treated with kindness, dignity and respect. Care was generally personalised and people’s health needs were followed up.
The home was rated Requires Improvement for Well-led. Inspectors found shortfalls in the environment, some risk assessments, end-of-life care plans and the detail of improvement plans. The home had improved from Requires Improvement at the previous inspection, and there was no required follow-up after this inspection.
Enough staff
Inspectors found enough staff to keep people safe and meet their needs. Staff responded promptly to requests for support.
“There were enough staff available to keep people safe and meet their needs.” from the report
Kind and respectful care
Staff treated people with compassion, dignity and respect. They understood people’s likes, dislikes and preferences.
“Our observations of staff interactions with people showed that people were treated with kindness, compassion, dignity and respect.” from the report
Good health support
Staff worked with health professionals and followed the guidance they received. Records showed staff acted promptly when people’s health needs changed.
“Staff spoke knowledgeably about individual people's health needs and records showed they had been proactive in seeking guidance and support from health professionals.” from the report
Personalised care
Staff knew people’s histories, interests and support needs. Activities included music, arts and crafts and quizzes.
“Staff's knowledge of people was really good. They understood people's history, likes, dislikes as well as their support needs.” from the report
Improvement plans lacked detail
needs fixingThe home had identified several areas for improvement, but its action plan did not include all the concerns found. It was not clear how or when all the shortfalls would be fixed.
“Not all concerns identified during the inspection were included on an action plan shared with us after the inspection.” from the report
Some care records were incomplete
needs fixingOne care plan contained inaccurate information and another moving and handling plan lacked details. This could create a risk for staff who were unfamiliar with a person.
“A lack of detailed or accurate information in people's care plans can pose a risk to staff who were not familiar with the people living in the service.” from the report
Dementia-friendly environment needed more work
needs fixingThe home had started making changes, such as photographs by bedroom doors, but needed more signage and contrasting colours. Some areas also needed redecoration.
“However, further work was needed with regard to developing a dementia friendly environment for people, such as signage and contrasting colours in different areas.” from the report
End-of-life plans lacked detail
needs fixingNo one was receiving end-of-life care during the inspection. However, the manager recognised that care plans needed to record people’s end-of-life preferences more fully.
“The manager was aware that care plans could be further developed to ensure people's preferences for end of life care were reflected.” from the report
Some risk assessments needed strengthening
needs fixingRisks relating to people’s skin integrity had not always been assessed effectively. Staff understood how to reduce the risks, and the home began using a recognised skin assessment tool after the inspection.
“We identified that risks associated with people's skin integrity had not always been effectively assessed.” from the report
- 01What actions have now been completed to improve the building, including marked carpets, damaged paintwork and the missing corridor handrail?
- 02How do you now make sure skin integrity risks are assessed and recorded for every person?
- 03How do you check that care plans are accurate and contain enough detail for staff who are new to the home?
- 04How are people’s end-of-life wishes discussed, recorded and reviewed with them and their families?
- 05How do you give people living with dementia a meaningful reminder of their meal choices before meals are served?
This was an unannounced comprehensive inspection covering all five CQC questions, including the premises and the care provided. This explanation was written from the published report of 22 May 2020 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, February 2019
Croft Manor Residential Home was rated Requires Improvement; inspectors found kind, personalised care but serious infection-control and management problems.
Inspectors visited without notice on 17 and 18 January 2019. They spoke with people living there, relatives, healthcare professionals, staff and managers. They also checked care records, medicines, complaints, accidents and quality checks.
People generally felt happy and safe. Inspectors found staff were kind, respectful and understood people's individual needs. Care was personalised, people were involved in decisions, and people received support with food, healthcare, activities and communication.
There were significant infection-control concerns, especially in the laundry. Mould, dirt, clutter and poor cleaning arrangements created a risk of cross infection. Medicines were usually managed safely, but records for boxed medicines did not reliably show how many tablets were in stock.
The home was rated Good for Effective, Caring and Responsive. It was rated Requires Improvement for Safe and Well-led. The overall rating was Requires Improvement. This was the first inspection since the service registered with CQC, so there was no earlier rating to compare with.
Kind and respectful staff
People and relatives described staff positively. Inspectors observed staff supporting people patiently and compassionately.
“We observed people were treated with kindness and compassion by staff.” from the report
Personalised choices
People helped shape their care and could choose how they spent their day, when they got up and where they ate.
“People were empowered to make their own decisions and choices.” from the report
Good healthcare support
People were supported to see healthcare professionals when needed. Staff shared information with hospital teams when people were admitted.
“People were supported to access healthcare services when needed.” from the report
Activities and communication
People had access to different activities, and staff used suitable approaches such as a whiteboard and picture-based information to support communication.
“People had access to a range of activities, including from external activity providers.” from the report
Serious laundry cleanliness problems
seriousThe laundry contained heavy mould, dirt, clutter and a broken tank lid. There was no effective system to stop clean clothing and linen becoming contaminated.
“We identified significant concerns with the cleanliness, maintenance and operation of the laundry.” from the report
Infection-control breach
seriousSome bathrooms and equipment were also not clean, and some infection-control training was overdue. Inspectors said these problems increased the risk of cross infection.
“The failure to operate effective systems to prevent and control the spread of infection was a breach of Regulation 12” from the report
Boxed medicines records
needs fixingStaff did not always record the number of tablets held in boxed medicines. This meant the home could not account for stock or know whether any medicines were missing.
“The arrangements for recording and monitoring the use of boxed medicines was not robust.” from the report
Quality checks missed problems
needs fixingAudits had not identified the laundry, bathroom and boxed-medicine issues. This meant managers did not have reliable oversight of important risks.
“The quality assurance processes were not robust.” from the report
- 01What has been done to remove the mould, dirt and clutter from the laundry, and how is its cleanliness checked now?
- 02How do you prevent clean clothes and linen from becoming contaminated in the laundry?
- 03How are boxed medicines counted and recorded now, and who checks the records?
- 04What changes have been made to quality audits so they identify infection-control and medicines problems promptly?
- 05How do staff now offer meal choices in a way that supports people living with dementia?
This was a planned first comprehensive inspection of the newly registered service and assessed all five CQC questions. This explanation was written from the published report of 21 February 2019 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 Manor Residential Home
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- May 2020Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Croft Manor Residential Home →
- February 2019Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Croft Manor Residential Home →
- January 2018
Registered with the Care Quality Commission on 19 January 2018.
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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