Croft Dene Care Home

Updated 13 May 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by 1 inspector and 1 Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Croft Dene Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Croft Dene Care Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed the information we held about the service, including the statutory notifications we had received from the provider. Statutory notifications are reports about changes, events or incidents the provider is legally obliged to send to us. We contacted the local authority commissioning and safeguarding teams, the local NHS infection prevention and control [IPC] team and Healthwatch to request feedback. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 2 people who used the service and 11 relatives about their experience of the care provided. We spoke with 7 members of staff including care staff, the activities co-ordinator, the registered manager, operations manager, and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We reviewed a range of records. This included care records for 4 people and multiple medicines records. We looked at the recruitment records for 3 staff and a variety of records relating to the management of the service, including policies and procedures.

We also received feedback from 1 health professional who was involved with the home. We requested additional information by email from the provider and continued to seek clarification to validate the evidence we found.

Updated 13 May 2023

About the service

Croft Dene Care Home is a care home providing accommodation and nursing or personal care for up to 43 people. Accommodation is provided over two floors. The environment had been adapted to meet the needs of people. At the time of our inspection 37 people were resident at the home.

People’s experience of using this service and what we found

The service was well-led. Action had been taken following the last inspection to ensure legal requirements were met and service improvements were made. Governance systems were effective in monitoring quality at the home. The registered manager worked in an open and transparent way and understood their responsibilities in relation to the duty of candour regulation.

Policies and procedures in relation to infection prevention and control (IPC) to prevent the spread of infections were in place. Arrangements were in place to support people to maintain contact with people important to them. This included indoor visits from relatives or friends and supporting people to maintain contact with the use of technology such as telephone calls.

Medicines were managed safely and reviews of incidents took place to assess if any improvements to staff practice could be made. Safe recruitment procedures had been followed and there were enough staff deployed to meet people’s needs. Systems were in place to safeguard people from the risk of abuse and the risks people were exposed to had been assessed.

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

People’s communication needs were met. Information was available to people in alternative formats to support their communication needs. End of life care plans were in place to ensure any wishes people had for their end-of-life care were recorded. Staff provided care and support which was person-centred to the individual needs of people. Systems were in place to investigate and respond to any complaints and to acknowledge any compliments.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 23 June 2022) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We carried out an unannounced focused inspection of this service on 17 and 22 March 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, good governance, duty of candour and fit and proper persons employed.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions safe, responsive and well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Croft Dene Care Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.