About the service:

The Croft is a residential service that provides care for up to 60 people. At the time of our inspection there were 43 people using the service. The service provided accommodation and personal or nursing care to older adults, in particular those with dementia. People lived in their own bedrooms. Rooms had ensuite bathroom facilities. There were also communal bathroom facilities, lounges and dining rooms.

People’s experience of using this service:

People’s experience of using the service was positive. People told us, “Yes I am being looked after here and yes of course I am safe”, “All the staff are very nice to me” and “Everyone should live here.” People were protected against avoidable harm, abuse, neglect and discrimination. The care they received was safe. People’s risks were assessed and measures put in place to reduce the risks. Staff received supervision and training, which provided them with the knowledge and skills to perform the roles they were employed to do.

Care was person-centred and focused on people living with dementia to ensure they lived rewarding lives. The care was designed to ensure people’s independence was encouraged and maintained. The management team had embraced continuous learning, and new ways of working. There was workplace culture that was open and honest, staff we spoke with provided positive feedback about the management team. The staff were committed to ensuring improvements continued to ensure the best care for people who lived at The Croft.

Rating at last inspection:

At our last inspection the service was rated Requires improvement and the report was published on (27 January 2018).

Why we inspected:

This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received. We inspect services rated ‘requires improvement’ within one year of our previously published inspection report. We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Further inspections will be planned for future dates.

The Croft is a residential care home situated in Amersham, Buckinghamshire. The service provides accommodation and personal care for up to 60 people. The service does not provide nursing care. At the time of our inspection there were 49 people using the service. The home is divided into four units each with its own lounge and dining area.

There was a registered manager in post. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The inspection took place on 23 and 27 November 2017 and was unannounced. Our previous inspection carried out in October 2016 found a breach of the Health and Social Care Act 2008.The provider was now compliant with the regulation.

People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided and both were looked at during this inspection. The service accommodates people across four separate units, each of which have separate adapted facilities. Two of the units specialises in providing care to people living with dementia.

We could see improvements had been made since our last inspection in relation to the atmosphere, culture and staff support. Staff told us they felt supported by senior staff. Comments we received included, “Managers are amazing, and support is phenomenal.” “Very supported.” “Happy and supported.” “I love it here, it’s so much better now.” They went on to say how much the service had improved since the new registered manager took over. Another member of staff said, “The management are good, [registered manager] is the best I’ve seen.”

The atmosphere was calm and pleasant we observed good interaction between staff and people living at The Croft. People were treated with dignity and respect. Staff knocked on doors before entering. One person told us how friendly and polite the staff were and that they always knocked on the door before entering. They went on to say they would recommend the service to a friend.

At this inspection we found staff received training in safeguarding people from abuse and neglect and demonstrated good knowledge of what to do if they suspected someone had been inappropriately treated. The provider had reported instances where this had occurred to the Local Safeguarding Authority.

Personal Emergency Evacuation Plans (PEEPs) were in place in the event of a fire.

Where people were required to have their fluids monitored this was not always recorded. We saw poor recording of people’s fluid intake. The registered manager acknowledged this was an area for improvement and we were aware they were looking at implementing a more robust way of recording people’s fluid intake.

Staff demonstrated a good understanding of the Mental Capacity Act 2005 (MCA). People had their capacity assessed when required and consent was obtained in line with legislation. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; policies and systems were in place to support this.

Where reviews of care were carried out, there were no records to show involvement with people or their families. However, we were told this was being implemented at the service and at the time of our inspection a review meeting with a person and their family was taking place.

Staff people and their relatives told us the service was well managed. Quality assurance systems were in place to monitor the quality of the service.

We have made a recommendation in relation to the management of medicines.

The Croft is a residential home situated in Amersham, Buckinghamshire. The home provides accommodation and personal care for up to 60 people. This service does not provide nursing care. At the time of our inspection there were 51 people who used the service. The home is divided into four units, each with their own lounge and dining area.

At the time of our inspection there was no registered manager in post. 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.

The home was overseen by the service’s regional manager, who visited the service four days every week. There were also two deputy managers who supported the regional manager. The provider was actively recruiting for a registered manager to run the home.

Our previous inspection carried out in December 2015 found several breaches of the Health and Social Care Act 2008 and associated regulations. We asked the provider to take action to make improvements to the management of medicines, meeting people’s social needs, investigating when people were found to have unexplained bruising and ensuring systems were in place to control and prevent infection. We carried out this inspection to see if the provider had made improvements and was meeting the current Regulations. We consider the provider had made significant improvements in previously breached Regulations. However, there were continued ineffective systems for the management of medicines. We have made a recommendation of the implementation of robust auditing to identify shortfalls.

People’s feedback about the home was mainly positive. One person told us, “Staff are kind especially [staff name]. The food’s not bad. We have exercises and all sorts of things.” A visiting professional told us, “The staff here are kind and considerate”.

People were safeguarded from abuse and neglect as staff demonstrated good knowledge of what to do if they suspected someone had been inappropriately treated. The provider reported instances where this had occurred to the local authority.

Staff had received training in safe handling of medicines and were competency-assessed to support them in the role. However, medicines were not always managed effectively. Staff had received training in areas such as mental capacity, infection control, moving and handling and safeguarding.

Regular supervisions did not always take place. However the regional manager was in the process of putting in place more robust procedures to ensure staff had supervisions on a regular basis.

People’s privacy was maintained and they were treated with respect by staff who knew the people they supported well. Staff appeared kind and considerate with people they supported. We saw several acts of kindness during our visit. For example, one person decided they did not want to sit in the dining room eating their lunch. Staff ensured the person was safely escorted back to their room at their own pace. The home had several agency staff at the time of our inspection. However, the agency staff had worked at the home for a continuous period of time and demonstrated they knew people well. One relative told us, “I don’t know the difference between agency staff and permanent staff; they are all good”.

Care plans and risk assessments did not always reflect current needs and in some cases instructions had not always been followed. For example, instructions from the district nurse were not always followed. We found one person did not have a risk assessment for self-administration of their medication. Involvement with people in terms of care plan reviews could not be identified. One person told us they had never seen their care plan.

Activities were planned and people were encouraged to participate. However,

When we visited the service on 27 November 2013 we had concerns how this standard was managed. This was because supervisions were not undertaken regularly which impacted on the support staff received. This potentially impacted on people who used the service as they could not be sure staff were supported to undertake their roles effectively.

We set a compliance action for the provider to improve practice. The provider sent us an action plan which outlined how they intended to become compliant.

We returned to the service on the 10 March 2014 to check if improvements had been made. We looked at supervision records and spoke with three members of staff. We found the provider had put in place measures to ensure staff supervision and appraisals were undertaken in line with the providers policy.

People told us that they felt they received good care. One person told us “I have no complaints about living here, the staff are very good and we get on well.” Another person told us “The food is good.” We saw that people’s independence was maintained through effective care planning and respecting people’s wishes around their needs.

The provider and staff had a working knowledge of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and how this impacted upon people using the service. Where people were deprived of their liberty, the correct processes were followed to ensure peoples dignity and human rights were upheld.

The provider had adequate numbers of skilled and experienced staff to ensure people’s needs were met. Where there were vacancies, the provider ensured that there were sufficient staff in place to ensure that staffing levels did not impact on people using the service.

We saw staff received training to assist them in their roles, however staff were not always receiving supervision in line with the providers policy. This meant staff were not always supported to deliver care, treatment and support safely and to appropriate standards

People told us staff treated them with respect in the way they talked to them. One person we spoke with said, “I don’t like staff addressing me by my name.” We heard staff used their formal title when speaking to them. This showed people were listened to and staff were respectful of the decisions made by people who use the service.

Information was displayed in the main reception and dining rooms in each unit, to advise people of their rights and choices. This meant that people using the service were given choice and was informed of the support on offer.

We observed staff engaged with people and offered them more food and drink throughout the lunch period. This showed there were choices of suitable food and drink to meet people’s nutritional needs.

One person told us, “The home gave me information to tell me what abuse is. I know what to do if abuses occur.” This showed people who used the service are aware of how to raise concerns of abuse

People we spoke with talked about whether staff could meet their needs. One person told us, “They are able to meet some of my needs but need training in others.” The service had arrangements in place to ensure staff received the necessary training. However, we found staff were not always supported to deliver care and treatment and support safely and to appropriate standards. Supervisions were not consistently held and there were no evidence to show appraisals had been undertaken.

A visiting professional told us that in their experience The Croft had a positive ethos and the staff there endeavoured to work in the best interests of the people using the service.

A person who had started using the service the day before our visit told us that the staff were all very nice and treated her with respect.

The person said that the staff generally respected her privacy and knocked on the door before entering her room. However, the person also told us that she was a bit surprised to find that a male care worker had been assigned to assist her when she had a bath. She said that her permission had not been sought beforehand.

Another person who had used the service for some time told us that she had always been well treated by staff. She said that she could go out when she wanted to. The staff were always helpful and treated her with respect.

The inspection took place on 8 and 9 December 2015 and was unannounced. We previously inspected the service on 11and 13 May 2015 and found that the service’s medicines procedures and recording practice needed improvement in order to maintain people’s safety consistently.

The service provides accommodation and personal care for up to 60 older people. This service does not provide nursing care. At the time of our inspection there were 55 people using the service. The service has a registered manager supported by a deputy manager.

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’s feedback regarding The Croft was critical. They told us that too many agency staff work at the home and this had an impact on the quality of care. Several members of staff had told us they had provided feedback to management about the lack of support they receive in carrying out their duties, however they felt nothing had changed.

Staff had received training in topics such as fire safety, manual handling, and mental capacity. However, staff supervision were not being held on a regular basis.

People’s privacy was not maintained as there were large white notice boards displayed throughout the home with personal information of people on display.

People were not protected by The Deprivation of Liberty Safeguards and had restrictions placed upon them without staff having the authorisation to do so.

Complaints were not listened to or acted on and this led to a failure to use this information to improve the quality of care received. Staff were kind and caring in their approach to the people who lived in the home.

The risk assessment process to identify risks to people and how they were to be eliminated or managed were not always being carried out or recorded. This meant people were not always being protected from identifiable risks to their health and safety.

Policies and procedures in relation to safeguarding of adults accurately reflected local procedures and included relevant contact information. All of the staff we spoke with were able to explain the procedures in relation to the safeguarding of adults.

People’s care plans did not always reflect the care that had been carried out. Accidents and incidents were not recorded accurately and had not been investigated appropriately.

We found where people sustained unexplained bruises, no action was taken to investigate or escalate them to the appropriate agencies. This placed people at risk of unsafe care and inappropriate care.

The décor of the home was in need of updating, some of the ceilings had large damp patches where water had leaked from one of the rooms.

We observed staff to be rushed and task focused and had little time to interact with people. We found that there were not sufficient numbers of staff to meet the needs of the people in the home.

We found that there were 11 staff in the building for 55 residents. Most of the residents were living with dementia and had a high level of need. Additional staff were a deputy and a shift leader however they did not work directly on the units and were in the office on both days of our visit.

The home has largely agency staff who work in the home due to difficulty in recruiting permanent staff. However the home tries to ensure the same staff are requested from the agency.

Medicines were not administered safely and in a timely manner. We saw the morning medicine round still being carried out at 11.a.m this meant that the people who required a lunch time dose of medicine would be at risk of receiving it too close to the morning dose. The medicine cupboard was observed to be left open and unattended on the second day of our visit. We were also aware that controlled medicine had not been correctly booked in in the appropriate book. Some stock of medicine did not reflect what was left in the medicine box. On the first day of our visit we were aware that two medicine errors had occurred.

Staff had received training in the administration of medicine. Quality assurance systems did not effectively assess or monitor the quality and safety of services provided. Activities were not planned in accordance to the people who were able to participate.

The provider was not meeting the requirements of the law. You can see what action we told the provider to take at the back of the full version of the report.