This inspection took place on 25 and 27 September 2017. The first day of our inspection was unannounced. The Croft is registered to provide accommodation for up to 21 people who require nursing or personal care. At the time of our inspection there were twelve people using the service.

At the last inspection in March 2017 we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.The breaches were:-

Regulation 9 Person-centred care

Regulation 11 Need for consent

Regulation 12 Safe care and treatment

Regulation 13 Safeguarding service users from abuse and improper treatment

Regulation 14 Meeting nutritional and hydration needs

Regulation 17 Good governance

Regulation 18 Staffing

Following our last inspection we asked the provider to take action to make improvements. During this inspection we found improvements had been made and there were no continued or new breaches of regulations.

There was not 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run. The provider had secured the services of a manager consultant with a background in mental health. Arrangements were in place to appoint a new manager and candidates were due to be interviewed on 28 September 2017.

People had care plan documents which were accurate, up to date and regularly reviewed. We found these described people’s individual needs and provided staff with a profile of people’s mental health needs. Where risks to individual people had been identified we found staff had been given guidance and advice on how to mitigate these risks.

Staff had been trained in safeguarding vulnerable adults. They told us they felt able to speak to the manager if they had any concerns

There were enough staff on duty. A new board on the wall told people who used the service who were their staff member for the day.

Staff provided appropriate support to people with dignity and respect. We found changes had been made in the service which promoted people’s independence.

Pre-employment checks were carried out on staff to ensure they were of suitable character and had the necessary skills to care for vulnerable people. Staff completed an induction when they first started work which supported them to get to know the home and people who used the service. Staff received regular supervision, appraisals and training. Staff had recently registered to undertake training in mental health.

The provider had used the knowledge and skills of a manager from another service to implement a programme of checks which ensured people were protected from living in an unsafe environment. These included, for example, fire safety and water temperature checks.

Accidents and incidents were recorded by staff. These were monitored by managers to ensure the right actions had been taken and prevent the same type of accident happening again.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Some people in the service were provided with additional staff hours to support them to carry out activities of their choice. Staff had begun to engage with people about the type of activities they would like to see provided.

Staff had completed food and fluid charts to monitor the food and fluid intake of people were at a nutritional risk. People made positive comments about the meals and we found people had a menu choice. Alternatives were available if people preferred other options.

We saw discussions had taken place with mental health professionals. The staff had made referrals to other health care profe

This inspection took place on 17, 18 and 23 May 2017 and was unannounced. This meant the staff and the provider did not know we would be visiting.

At our last inspection of The Croft in December 2016 we reported that the provider was in breach of the following regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014:-

Regulation 9 Person Centred Care

Regulation 12 Safe care and treatment

Regulation 14 Nutrition and Hydration.

Regulation 15 Premises

Regulation 17 Good governance

Regulation 18 Staffing

The overall rating for this service was 'Inadequate' and the service was placed in 'special measures'. This is where services are kept under review by CQC and if immediate action has not been taken to propose to cancel the provider's registration of the service, the location will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

Following the last inspection the provider sent us an action plan. At this inspection we found there were some improvements. However, we also found there were further regulatory breaches.

The registered manager was not present in the service during the 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.

We found there were discrepancies between the number of some of the medicines in the home and the records. We could not be reassured people had received their medicines in the way in which they were prescribed.

The service failed to identify and record risks people posed to themselves and others, as well as have in place actions and guidance to support staff on how to reduce these risks. This meant people who used the service continued to be at risk.

People had in place Personal Emergency Evacuation Plans (PEEPs), these plans were available to emergency services to assist them evacuate people from the building. Following concerns we found during the inspection we asked the local fire safety officer to visit the home. They made recommendations to the staff on how to improve fire safety on the premises.

We looked at staff records and found prospective staff had completed application forms and undergone Disclosure and Barring Service checks. However, we found references had not been obtained for two staff before they had started to work in the service. This meant recruitment checks were incomplete and staff were working in the service without thorough checks on their background in place.

As a result of the home requiring refurbishment, there were shortfalls in cleanliness.

Staff had failed to support people who had lost weight. One person had a low body mass index (BMI) which placed them at increased risk of cardiac arrest. Staff took action when we raised the issues.

We found staff were keen to learn about their role and people’s conditions. We found staff had not received sufficient support, training and guidance to enable them to care for the people who lived at The Croft. We found records which were incorrect and other issues within records which staff were unable to explain.

We saw the service did not comply with the requirements of the Mental Capacity Act 2005. Staff did not understand when to use mental capacity assessments and undertake best interests’ decisions. This meant people who used the service were making choices when their mental capacity was impaired and no checks were in place to ensure they understood the consequences of their decisions. As a result people were at risk of inappropriate care.

We saw food was freshly prepared for people who were given a choice of menu. Kitchen staff were aware of people’s dietary require

This inspection took place on 28, 29 and 30 December and the inspection was unannounced. The Croft provides accommodation for up to 25 people who require personal care. The people living in the home have a range of mental health needs and learning disabilities.

At the last inspection on 4 August 2014 we rated the service as “Good” and the service met the regulatory requirements.

The home had 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staff interacted with people in a friendly manner.

We checked to see if people were given their medicines in a safe manner and found there were no gaps in the Medicine Administration Records (MAR). However we found medicine profiles of people giving information on their allergies and photographs were missing. This put people at risk of being given the wrong medicines.

Risk assessments had been carried out in relation to the building, although not all staff had signed these. We found risk assessments for people’s mental and physical health to be missing from their records. This meant staff did not always have the guidance in place to help them mitigate the risks to people using the service.

Staff recorded incidents in the home; we found the registered manager reviewed the incidents before compiling their monthly report. We found the incidents had not been reviewed in sufficient detail to ensure people in the home were kept safe. CQC requires registered services as a part of their registration to notify the commission when there are incidents of a safeguarding nature or the police are called out to a home. We found not all of the notifications had been made.

We found areas of the home to be unclean and the decoration was in a poor state of repair. The local Infection Control team had visited the home in October and December. They had highlighted the lack of cleanliness in October and found there was no change in December. The registered manager had put together an improvement plan to redecorate the home but was unsure of the budget available to them at the time of our inspection to carry out the plan.

The registered provider carried out appropriate pre-employment checks to ensure staff were safe to work with vulnerable people.

Staff were not supported to carry out their role through regular supervision and appraisal. We found staff were caring for people without having had training to meet people’s needs. For example we found not all staff had received training in mental health. No staff members had received training in meeting the needs of people with learning disabilities or diabetes.

We found the needs of people with specific dietary needs had not been addressed in the service. This meant people were put at risk of receiving inappropriate foods.

Staff supported people to attend medical appointments. We found one person who had lost weight and wanted to see their GP about feeling unwell. The person was not supported to convey their possible symptoms to their GP. We also found a staff member had told a clinician a person was improving following an incident when the police were involved. The staff member did not record if they had discussed with the clinician the person’s behaviour. The clinician made a decision based on inaccurate information. This meant the people were put at risk of clear communication between the service and its partners.

People had additional one to one staff hours allocated to them and we found they chose how to spend this time. Some people chose to go out with staff support. We also observed staff engaging people in board games.

We found the service made applications to deprive people of their liberty as guided by the Deprivation of Liberty Saf

The inspection took place on 04 August 2015. The inspection was unannounced.

The home provides care for up to 25 people with mental health care needs. On the day of our inspection there were 22 people using the service.

The home had a registered 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.

We spoke with care staff who told us they felt supported and that the registered manager was always available and approachable. Throughout the day we saw that people and staff were very comfortable and relaxed with the deputy manager and staff on duty. The atmosphere was calm and relaxed and we saw staff interacted with people in a very friendly and respectful manner.

Care records contained risk assessments. These identified risks and described the measures and interventions to be taken to ensure people were protected from the risk of harm. The care records we viewed also showed us that people’s health was monitored and referrals were made to other health care professionals where necessary. We saw records were kept where people were assisted to attend appointments with various health and social care professionals to ensure they received care, treatment and support for their specific conditions.

We found people’s care plans were written in a way to describe their care, treatment and support needs. These were regularly evaluated, reviewed and updated. The care plan format was easy for people or their representatives to understand. We saw evidence to demonstrate that people or their representatives were involved in their care planning.

The staff that we spoke with understood the procedures they needed to follow to ensure that people were kept safe. They were able to describe the different ways that people might experience abuse and the correct steps to take if they were concerned that abuse had taken place.

Our observations during the inspection showed us that people were supported by sufficient numbers of staff. We saw staff were responsive to people’s needs and wishes.

When we looked at the staff training records they showed us staff were supported to maintain and develop their skills through training and development activities. The staff we spoke with confirmed they attended both face to face and e-learning training to maintain their skills. They told us they had regular supervisions with a senior member of staff, where they had the opportunity to discuss their care practice and identify further training needs. We also viewed records that showed us there were robust recruitment processes in place.

The registered manager and staff understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS).

During the inspection we saw staff were attentive and caring when supporting people. Comments from people who used the service were very consistent stating they were happy with the care, treatment and support the home provided. Other professionals we spoke with were positive about the care and support people received.

We observed people were encouraged to participate in activities that were meaningful to them. For example, we saw staff spending time engaging people with people on a one to one basis, and others went out shopping with their support workers.

We saw people were encouraged to eat and drink sufficient amounts to meet their needs. We observed people being offered a selection of choices. Some people prepared their own meals.

We found the building met the needs of the people who used the service. We were told that work on the refurbishment of the home will continue throughout the remainder of the year.

We saw a complaints procedure was displayed in the main reception of the home. This provided information on the action to take if someone wished to make a complaint.

We found an effective quality assurance system operated. The service had been regularly reviewed through a range of internal and external audits. Prompt action had been taken to improve the service or put right any shortfalls they had found. We found people who used the service, their representatives and other healthcare professionals were regularly asked for their views.

The inspection team was carried out by a single inspector. We gathered evidence against the outcomes we inspected to help answer our five key questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read our full report.

Is the service safe?

People told us that they felt their rights and dignity were respected.

Systems were in place to make sure that managers and staff learn from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduces the risks to people and helps the service to continually improve.

Staff knew about risk management plans and showed us examples where they had followed them. People were not put at unnecessary risk but also had access to choice and remained in control of decisions about their care and lives.

The registered manager sets the staff rotas, they take people’s care needs into account when making decisions about the numbers, qualifications, skills and experience required. This helps to ensure that people’s needs are always met.

Is the service effective?

People’s health and care needs were assessed with them, and they were involved in writing their plans of care. Specialist dietary needs had been identified where required. People said that their care plans were up to date and reflected their current needs.

One person had an full time outreach support worker and told us that the service had helped them to find them. Other people we spoke with were also supported by an outreach worker's.

Is the service caring?

We spoke with ten people being supported by the service. We asked them for their opinions about the staff that supported them. Feedback from people was positive, for example; “the staff are great”, “they do what I ask them, sometimes I help to write my care plan”, “I feel I can talk to staff about anything."

When speaking with staff it was clear that they genuinely cared for the people they supported.

People using the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised these were taken on board and dealt with.

People’s preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes.

Is the service responsive?

People knew how to make a complaint if they were unhappy. One person said that they had made a complaint and were satisfied with the outcome.

The service worked well with other agencies and services to make sure people received care in a coherent way.

Is the service well-led?

The service has a quality assurance system, and records showed that identified problems and opportunities to change things for the better were addressed promptly. As a result the quality of the service was continuously improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the service and quality assurance processes were in place. This helped to ensure that people received a good quality service at all times.

The arrangements for supporting people to make decisions about their daily lives and preferences were recorded in their care plans. Each person was supported to take appropriate risks to promote as much independence as possible. However, there was no documentary evidence available that people had agreed to the content of their care plans or risk assessments.

The relationships between staff and the people who they supported were good and personal support was provided in a way that promoted and protected their privacy and dignity. This was confirmed when we spoke with six people who used the service.

Suitable arrangements were in place for handling complaints and for protecting people from abuse.

There was a competent staff team who had the training, skills and experience to meet the specific conditions of the people who they supported.

At our last inspection carried out on 19th November 2012 we identified concerns with outcome 4 (HSCA Regulation 9) care and welfare of people who used services. We found the provider was not providing effective, safe and appropriate, personalised care and treatment and support through assessment and care planning.

During this inspection we found the provider had made significant improvements to ensure people received effective personalised care, treatment and support.

The arrangements for supporting people to make decisions about their daily lives and preferences were recorded in their care plans. Each person was supported to take appropriate risks to promote as much independence as possible.

We saw relationships between staff and the people who they supported were good. Personal support was provided in a way that promoted and protected their privacy and dignity. This was confirmed when we spoke with two people who used the service.

People told us they had a monthly meeting with their key worker. They said they were always consulted and were always asked about what was important to them. One person told us “They take notice of me and what I want and we always agree on the best way forward.

The deputy manager told us they always ensured they carefully assessed the care and support needs of people wishing to come and live in the home.

We saw care plans were not sufficiently detailed to show how staff should help people to meet their needs. This meant staff did not always have the information they needed to support each person and keep them safe.

The arrangements for supporting people to make decisions about their daily lives and preferences were recorded in their care plans. Each person was supported to take appropriate risks to promote as much independence as possible. However we saw some people's risk assessments had not been agreed and signed.

The relationships between staff and the people who lived at the home were good and personal support was provided in a way that promoted and protected their privacy and dignity.

The meals provided by the home were satisfactory and gave people a varied, nutritious diet.

Suitable arrangements were in place for handling complaints and for protecting people from abuse. People told us they could share any worries with the staff and felt their views were listened to.

There was a stable and competent staff team who had the training, skills and experience to understand the specific conditions of the people who lived there.

Four service users said that they were happy with the refurbishment plans for the building.

Overall, peoeple said that they were very satisfied with the care and support that they recieved. One person said, “I am involved in keeping any information about my life up-to-date, this is important to me because one day I want a place on my own. I have a key worker, and together we are planning for the time when I can live independently”.

People who used the service said, "The staff here are great, we are always consulted about everything. We have our own key worker’s, and we write updates in our support plan together".

"We have regular meetings and we always have a list of things we want to discuss. Sometimes we might not be happy about things that are going on, but the manager will always sort these out for us".