Our inspection took place on 12 October 2017 and was unannounced. At our last inspection we rated the service as ‘Requires Improvement’ and identified three breaches of regulation. These related to inconsistent risk assessment calculations seen in people’s care plans, incomplete recruitment records and inconsistencies in the accuracy of care documentation. At this inspection we found the provider and registered manager had taken action, and were now meeting all regulations.

Croft House provides nursing and residential care for up to 68 people. There are three separate units within the home providing residential, nursing and dementia care. All bedrooms are single occupancy with en-suite facilities. The home is situated in its own grounds with car parking facilities in the village of Gawthorpe. At the time of our inspection there were 62 people using the service.

There was a registered manager in post when we inspected, however they were not present for the inspection as they were on annual leave. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us they felt safe living at Croft House Care Home, and we saw risks associated with their care and support were well managed. Staff understood how to identify signs of potential abuse and how to report these. We saw accidents and incidents were reported and investigated appropriately. Maintenance and servicing records showed this was up to date.

Staff were recruited safely and deployed in sufficient numbers to provide care and support. We saw staff were always visible and able to spend time interacting with people in a meaningful way.

Medicines were managed safely. Records were complete, storage was appropriate and secure and there was clear guidance in place to ensure people received ‘as-and-when’ medicines safely.

People and their relatives told us staff had the skills and training to provide effective care. Staff had a thorough induction and access to on-going training and support to help them remain effective in their roles.

There was a good approach to the management of people who lacked capacity to make decisions for themselves, and the provider recognised when applications for Deprivation of Liberty Safeguards (DoLS) were needed.

People told us they enjoyed the food served in the home, and we made mainly positive observations during the lunchtime meal service.

We saw people had good access to health and social care professionals when this was required.

People and their relatives gave consistently good feedback about the caring nature of staff, and our observations confirmed this. People were involved with writing care plans, which were personalised, and received support to remain as independent as possible. There was a good approach to the management of privacy and dignity.

The provider assessed people’s needs before they began using the service, and used this information to write responsive care plans that were kept up to date. Staff attended a handover at the start of their shift which ensured they had access to up to date information about people’s needs.

There was a range of activities people could join in with, and we saw people had opportunities to access the local community.

There were policies in place to ensure complaints were recorded and actioned appropriately, although we found concerns raised verbally were not being recorded. We made a recommendation about starting to record verbal concerns, even when these were not formal complaints.

We received good feedback about the registered manager, and saw they were proactive in measuring, monitoring and improving quality in the service. People, their relatives and staff were encouraged to be involved in the runni

We inspected Croft House Care Home (called ‘Croft House’ by the people who live and work there) on 20, 22 and 26 July 2016. The first day of the inspection was unannounced. This meant they did not know we were coming. At the last inspection in November 2015 we rated the home as inadequate in every domain of care and inadequate overall and placed it in special measures. We also took enforcement action by serving the provider with notice of our intention to de-register and close the home if significant improvements were not made. This inspection was to see whether the issues we identified had been resolved.

Croft House contains four units over two floors. Downstairs are two nursing units, one with 18 beds and one with 12 beds. On the first floor there is a small residential unit with 12 beds and a dementia unit that has 24 beds. On the days we inspected there were 27 people in the units upstairs and 18 people in the units downstairs. There are stairs and lifts to the first floor. The home has dining and lounge areas in each unit, four conservatory areas downstairs and a large garden which is accessible to the people.

The service did not have a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

After the last inspection a ‘peripatetic’ manager had been appointed; their role was to make improvements at the home while the provider recruited a new registered manager. At the time of our inspection the peripatetic manager was still in post and a new manager had been recruited; they were in the process of transitioning into the role from their current home. The plan was for the new manager to apply to register with CQC when they became the home manager full time in August 2016.

We took enforcement action after the last inspection. At this inspection we checked to see if improvements had been made in all the areas we identified. We found that all aspects had been addressed either fully or partially. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

As the previous inspection in November 2015 rated the home as inadequate we placed it into ‘Special Measures.’ At this inspection we found there had been improvements which were sufficient for the service to be rated as requires improvement overall with no inadequate domains. This meant the service could come out of special measures.

At the last inspection in November 2015 we identified issues with the accuracy of people’s risk assessments. At this inspection the quality of risk assessment was mixed. Some were completed properly and others were not, and some were missing entirely. This constituted a continuous breach of Regulation 12 of the Health and Social Act 2008 (Regulated Activities) Regulations 2014.

Recruitment records did not include prospective employees’ full employment history and this was not investigated with them and recorded at interview. This was a breach of Regulation 19 of the Health and Social Act 2008 (Regulated Activities) Regulations 2014.

Although pressure area care and pressure ulcer management had improved, we found issues with the adherence to pressure ulcer treatment and prevention care plans. This was a continuous breach of Regulation 12 of the Health and Social Act 2008 (Regulated Activities) Regulations 2014.

Feedback from people about the food was all positive and we saw food and fluid care plans and risk assessments were much improved. However, we found issues with the recording of food and fluids for people either losing weight or at risk of weight loss. This was a breach of Regulation 17 of the Health and Social Act 200

The inspection took place on 19 and 20 November 2015 and was unannounced. The service was last inspected on 10 February 2014, this was a focussed inspection and the service was found to be compliant in the one key question which was inspected.

This inspection was in response to concerns which had been raised by the local authority who commissioned services at the home. These concerns related in particular to the Elderly Mental Infirm (EMI) unit, which offers care provision to up to 24 people with mental health conditions including advanced dementia and people who display behaviour which challenges others. The concerns related to the amount of incidents which had been occurring on this unit where people who used the service were assaulting each other.

Croft House Care home is a large building laid out over two floors. On the ground floor there are two general nursing care units, one with 18 beds and the other with 12 beds. On the first floor there is a small residential unit with 12 beds and the Elderly Mentally Infirm (EMI) unit with 24 beds. On the days of our inspection there were 61 people living at the home.

There was no registered manager in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There had been a manager appointed to the service and there was a deputy manager, neither were present on either of the days during our visit. The Regional director arrived during the morning of the first day of our inspection and was present for the remainder of the inspection.

We found the standards of care in the service had deteriorated significantly since our last inspection. There were multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

We found people’s care needs had not been adequately or accurately assessed and there was no care plan in place for one person who lived at the service. People’s care plans were out of date and the information did not reflect their current needs or describe the care which required by them or was being given to them.

We found people in the service were not treated with dignity and respect. Some of the people living in the service were unable to access the toilet without assistance and were being left for long periods without access to assistance. Staff did not recognise how people’s dignity could be promoted and did not assist people promptly when they needed help, as people did not have access to care bells or were unable to use them.

The people living in the service were not asked for their consent for care to be carried out. The provider and the staff failed to recognise restrictive practices which were in place. Mental capacity assessments were not carried out for the people living in the service to measure whether they were able to make their own decisions and which decisions they were able to make. Where people’s liberty was being restricted there were very few Deprivation of Liberty Safeguards in place.

There were very few risk assessments in place for people in the service and those that were in place were not adequate to identify and reduce identified risks to keep people safe. We found large numbers of people were left in bed as a matter of course, even when they were expressing that they did not want to be in bed. People who remained in bed were not receiving adequate pressure area care and there were incidences of serious pressure areas in the service as a result. People who had pressure area wounds were not receiving the correct treatment to ensure that their wounds would heal, and records of treatment and visits from external health professionals were not detailed.

Staff did not recognise safeguarding incident

This was a follow up inspection to check on the action taken to address concerns identified during our previous visit. This was in relation to people’s care, treatment and support within the general nursing unit in the home.

During our visit we spoke with three people who lived on the general nursing unit and one relative to gain their views. They told us they were happy with the care and support provided by the staff on the unit, and said staff were responsive and caring.

We spoke with five members of staff from the general nursing unit who were knowledgeable about the care and support needs of the people living in the unit. During our visit we observed people’s experiences of living in the home and their interactions with each other and with staff. We saw staff spoke kindly and respectfully to people living in the home. They interacted well with people as they supported them with activities such as eating their meals at lunchtime, and taking their medication.

We reviewed three people’s care records and found they provided clearly written information which provided a clear picture of the needs and preferences of each person. We found information relating to people’s care and well-being was maintained in a single file which staff reported made it easier for them to access, and record information about each person throughout the day.

People who lived in the home told us staff involved them in decisions about their treatment and care and how staff acted in accordance with their wishes. Relatives told us that communication with the home was good. A relative explained: “The staff are excellent and I am very happy with the care my relative receives.”

During our inspection we observed staff on the general nursing unit appeared to be task orientated and were not pro active in providing people with any meaningful physical or mental stimulation. For example, we saw people were left unattended for over half an hour in the lounge area. People’s welfare and safety were at risk due to the lack of positive and meaningful interaction.

The manager told us the home they had been successful in recruiting staff and greatly reduced their use of agency staff. People living in the home and relatives spoken with confirmed the staffing levels had increased throughout the home and were complimentary about the staff. However, staff told us there were still times when the staffing numbers fell below the expected level.

People who lived in the home and their relatives said they knew who to speak to if they had a worry or concern. They told us they felt able to make comments and were confident the staff or manager would do all they could to put it right. One relative said; “I had concerns about the lack of staffing and so I brought it to the manager and to other people's attention and it has now been sorted.”

During our visit we spoke with ten people who live in the home and two relatives

who were visiting. Most of the people on the Dementia unit were unable to talk to us about the care and support they receive because they are at differing stages of diagnosed dementia so we spent time observing people and observed the way staff supported people but were unable to gain peoples views.

All the people spoken with understood their care and the support they need. They told us that they are encouraged to make their own decisions about their daily activities. They were also very positive about the staff and the support they receive. Some of their comments were:

"If I want anything I can have it"

“Staff respond to the bell they are very good”

“You may find another place just as good but you will find none better”

“It’s lovely here. I love the company the food is good even if I have to have it soft”

“ We get frequent drinks and the staff will always makes us a drink if we want one”

“ The staff are very good and kind”

Their relatives also shared this view. One relative said “The staff are so kind and caring some are real treasures”

People explained how staff discussed their care with them and involved their family in this.

They told us that staff treated them in a dignified way. Relatives also spoke positively

about the attitudes of the staff team and said they were always made to feel welcome and

their views were respected and acted on.

Each person spoken with said they felt safe at the home and that people got on well

together most of the time. They said they have never had any concerns during their time at the home. No one had had to make a complaint. One person said, “Only once I was being looked after by someone and I told them that they were rushing me. This staff member stopped and took their time so I was pleased”

Relatives made comments about the need for more staff. They said that staff were very caring and tried to tend to each persons needs but sometimes people had to wait for their food because of the demands made on staff and the lack of staff available. They were especially concerned about the number of staff on duty at night.

People did say they had been asked to complete questionnaires about their views on the care and services provided.