The Croft (RCH) Limited The Croft (RCH) Limited Inspection report Hooke Hill Freshwater Isle of Wight PO40 9BG Tel: 01983752422 Date of inspection visit: 16 May 2019 20 May 2019 Date of publication: 23 July 2019 Ratings Overall rating for this service Good Is the service safe? Good Is the service effective? Good Is the service caring? Good Is the service responsive? Good Is the service well-led? 1 The Croft (RCH) Limited Inspection report 23 July 2019 Requires Improvement Summary of findings Overall summary About the service: The Croft (RCH) Limited is a residential care home that provides accommodation and older people and adults living with a mental health condition. The service is registered to accommodate up to 21 people. At the time of our inspection, there were 16 people living at the service. People's experience of using this service: People were happy living at The Croft and felt safe. There were enough staff to meet people's needs and they had been recruited safely. Staff received appropriate training and support to enable them to carry out their role effectively. Appropriate safeguarding procedures were in place to protect people from the risk of abuse. Staff knew how to report concerns and were confident that anything they raised would be taken seriously by management. Medicines were managed safely and in accordance with current regulations and guidance. There were systems in place to ensure that medicines had been stored and administered appropriately. Staff sought people's consent and supported people to make choices about their care. However, where people lacked capacity to make certain decisions, this was not always assessed and recorded appropriately in line with legislation. Staff treated people with kindness and compassion. Staff had developed positive relationships with people and knew what was important to them. People were treated with respect and dignity. People had clear, detailed and person-centred care plans, which guided staff on the most appropriate way to support them. There was a clear management structure with staff being supported by the registered managers and provider. People, staff and professionals commented positively about the management of the service and felt that it was well-led. The provider was engaged with the running of the service and staff and people told us they were approachable. Quality assurance systems were not always completed in a robust and consistent manner. They had not clearly identified where improvements were required to address the concerns we found. Rating at last inspection: The service was rated Requires Improvement at the last full comprehensive inspection, the report for which was published on 20 June 2018. 2 The Croft (RCH) Limited Inspection report 23 July 2019 Why we inspected: This was a planned inspection based on the previous inspection rating. Follow up: There is no required follow up to this inspection. However, we will continue to monitor the service and will inspect the service again based on the information we receive. For more details, please see the full report which is on the CQC website at www.cqc.org.uk 3 The Croft (RCH) Limited Inspection report 23 July 2019 The five questions we ask about services and what we found We always ask the following five questions of services. Is the service safe? Good The service was safe. Details are in our Safe findings below. Is the service effective? Good The service was effective. Details are in our Effective findings below. Is the service caring? Good The service was caring. Details are in our Caring findings below. Is the service responsive? Good The service was responsive. Details are in our Responsive findings below. Is the service well-led? The service was not always well-led. Details are in our Well-Led findings below. 4 The Croft (RCH) Limited Inspection report 23 July 2019 Requires Improvement The Croft (RCH) Limited Detailed findings Background to this inspection 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. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Act, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014. Inspection team: The inspection was conducted by two inspectors. Service and service type: The Croft (RCH) Limited is a care home registered to accommodate up to 21 people who need support with personal care. The service had two managers registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. Notice of inspection: We did not give notice of our inspection. What we did: Before the inspection, we reviewed the information we had received about the service, including previous inspection reports and notifications. Notifications are information about specific important events the service is legally required to send to us. We also considered information the provider sent us in the Provider Information Return. This is information we require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make. During the inspection we spoke with six people living at the service. We spoke with the nominated individual, the registered managers, a cook, a visiting hairdresser and three members of care staff. We looked at seven people's care records, staff training and recruitment files, records of accidents, incidents and complaints, and audits and quality assurance reports. 5 The Croft (RCH) Limited Inspection report 23 July 2019 Following the inspection, we gathered further information from two external health and social care professionals. 6 The Croft (RCH) Limited Inspection report 23 July 2019 Good Is the service safe? Our findings Safe – this means we looked for evidence that people were protected from abuse and avoidable harm People were safe and protected from avoidable harm. Legal requirements were met. At our last inspection in May 2018, we identified a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had failed to ensure safe medicines management and the safety of people. At this inspection we found action had been taken and there was no longer a breach of this regulation. Using medicines safely: • People were supported to take their medicines safely and as prescribed. • There were suitable systems in place to ensure that medicines were securely stored, ordered and disposed of correctly and safely and in accordance with best practice guidance. • Staff had been trained to administer medicines to people appropriately and their competency was checked regularly to ensure they remained safe to do so. A staff member said, "I shadowed someone and then they observed me to make sure I did everything correctly." • Medicines administration records (MAR) were completed correctly and indicated that people received their medicines as prescribed. MAR checks were completed daily to help ensure that no medicine errors had occurred. • A medicine audit was completed weekly, which was followed up by a more detailed medicine audit being completed monthly. This helped to ensure medicines were always available to people and being provided as prescribed. • Clear information was available to staff about how people preferred to receive their medicines. For example, one person's medicines record stated, 'I am happy to take my medicines one at a time from a spoon. I don't mind if I take it with juice or water.' • Each person who needed 'as required' (PRN) medicines had clear information in place to support staff to understand when these should be given, the expected outcome and the action to take if that outcome was not achieved. • Safe systems were in place for people who had been prescribed topical creams. • People were supported to manage their medicines independently, where appropriate. Risk assessments were in place to ensure that where this was done, it was done so safety and with the appropriate level of support. • Medicines subject to additional controls by law were stored in accordance with legal requirements. Assessing risk, safety monitoring and management: • Risks to people were assessed, recorded in their care plans and updated when people's needs changed. Risk assessments in place included areas such as, moving and positioning, skin integrity, medicines management, the use of bed rails and behaviours. Risk assessments were detailed and provided staff with clear information about what the risk was and actions they should take to mitigate the risk. • We found that where a person was at risk of developing pressure sores, there was clear guidance available 7 The Croft (RCH) Limited Inspection report 23 July 2019 to staff of actions they should take to prevent skin damage. This guidance highlighted that the persons position should be changed every two to three hours. The monitoring chart in place for this person demonstrated staff followed this guidance. However, we found that where a specialist mattress was in place for a person to help reduce the risk of skin damage, there was not a process in place to help ensure that the mattress was set correctly for the persons weight. This was discussed with one of the registered managers and immediate action was taken to amend the monitoring chart to incorporate mattress setting checks. • People who were at risk of malnutrition and dehydration had clear and up to date information within their risk assessment of how this should be monitored and managed by staff. This included information about their likes and dislikes of certain food and the implementation of food and fluid charts, so that their intake could be closely monitored. • Where monitoring charts were in place for people's food and fluid intake, position changes and weight, these were being completed and analysed appropriately to manage risks. • Equipment such as hoists, and fire safety equipment were serviced and checked regularly. • Personal evacuation and escape plans had been completed for each person, detailing action needed to support people to evacuate the building in the event of an emergency. • Contingency plans were in place, which helped to ensure that people were provided with consistent care and support in the event of an emergency or disruptive conditions. Preventing and controlling infection: • The home was clean, tidy and odour free. Domestic staff were employed within the service and staff completed regular cleaning tasks in line with set schedules. • People commented positively on the cleanliness of the service. One person said, "It's always kept nice and tidy. Its lovely and clean" and another person commented, "They keep it clean, they sort my clothes and change my bedding." • There were processes in place to manage the risk of infection and personal protective equipment (PPE), such as gloves and aprons was available throughout all areas of the home. Staff were seen using these when appropriate. • Attempts had been made to help ensure that there was a dirty to clean flow for laundry to prevent cross contamination. For example, following the laundering of people's clothes these were stored outside the laundry room away from dirty washing. However, we found that clean bedding was stored in an open shelving area near the washing machine, which was an infection control risk. This was discussed with the registered managers, who confirmed that discussions were underway in relation to this and there were plans for this area to be covered with doors. Systems and processes to safeguard people from the risk of abuse: • People told us they felt safe and secure living at The Croft. One person said, "It's all good here. I am fine, I have no worries." • There were robust processes in place for investigating any safeguarding incidents. We saw records which confirmed that where abuse was suspected, action had been taken immediately and thoroughly investigated. There were systems in place so that any concerns would be reported to CQC and the local safeguarding team when needed. • Staff had received training in safeguarding adults and knew how to recognise and report abuse to protect people. Staffing and recruitment: • There were enough staff to meet people's needs and keep them safe. Throughout the inspection we observed that people were given the time they required and were not rushed by staff. Where people rang their call bells, we saw staff attended to these promptly. • Staffing levels were determined by the number of people using the service and the level of care they 8 The Croft (RCH) Limited Inspection report 23 July 2019 required. • Staff told us they did not feel rushed in their roles and felt the level of staffing had improved. A staff member said, "Ideally it would be better to have a few more in, but [the registered manager] will always step in. We raised [staff levels] with [the nominated individual]. She is dealing with it, she's got a few more people in." Another staff member told us, "Staffing levels are fine. We spend a lot of time with [people]. We have a chat, sit with them and reassure them if we need to." • Short term absences were covered by existing staff members working additional hours or one of the registered managers working directly with people. • Recruitment checks had been completed to ensure that new staff employed were suitable to work at the service. This included disclosure and barring service (DBS) checks, obtaining up to date references and investigating any gaps in employment. Learning lessons when things go wrong: • Where incidents occurred, these were documented within people's care records, including any follow up action taken to prevent a reoccurrence. However, the provider did not have a system in place to monitor accidents and incidents, or to identify any patterns or trends. The impact of this was minimised due to the small number of people being supported, which meant that staff were in regular contact with people and were aware of their welfare. We discussed this further with the registered managers, who reassured us they would implement a process to identify any themes and trends. • Staff were given information about any incidents that had occurred during the handover between shifts. This meant that staff could provide support to people that recognised any impact on their wellbeing. 9 The Croft (RCH) Limited Inspection report 23 July 2019 Good Is the service effective? Our findings Effective – this means we looked for evidence that people's care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence People's outcomes were consistently good, and people's feedback confirmed this. Ensuring consent to care and treatment in line with law and guidance: The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether any restrictions on people's liberty had been authorised and whether any conditions on such authorisations were being met. • Where people did not have capacity to make decisions, MCA assessments and best interest decisions were not always recorded appropriately. For example, where people had a DoLS in place, people's care documents did not contain evidence that a clear process had been followed to assess people's capacity to understand why the DoLS was in place. We discussed this with the provider, who showed us documents that had previously been used to record this information. They informed us they would implement these with immediate effect to ensure evidence of capacity assessments and best interest decisions was completed correctly. • Staff were knowledgeable about how to protect people's human rights in line with the MCA and received regular training on this topic. One staff member told us, "The MCA is about where people lack the capacity to understand, retain and make a decision around their care or an aspect of their life, like their finances." • During the inspection, we observed staff seeking people's consent before assisting them with all aspects of their care. • Where people were able to, consent forms had been signed and recorded in their care plans regarding the care and support they received. • Applications for DoLS had been submitted to the appropriate authorities by the management team, as required. Staff support: induction, training, skills and experience • People told us they received effective care from staff which met their needs. One person said, "Oh yes, they [the staff] look after me. They are very good." • New staff completed an induction programme before supporting people on their own. This included a period of shadowing a more experienced member of staff, learning about key documents and the 10 The Croft (RCH) Limited Inspection report 23 July 2019 completion of essential training. • Staff had completed a range of training to meet people's needs effectively, such as safeguarding, fire safety, moving and handling and infection control. A staff member said, "They are very good for training here, they let us know when anything is next due." • The registered managers used a training matrix to monitor staff training, which we reviewed. Where we identified gaps in the training matrix, we raised this with one of the registered managers and following the inspection, they provided us with evidence that these staff members had since completed the required training. • Staff told us they felt supported in their roles by the registered managers and the provider. • Staff received regular one-to-one sessions of supervision, which they told us they found useful. These provided an opportunity for the registered managers to meet with staff, discuss their training needs, identify any concerns, and offer support. Assessing people's needs and choices; delivering care in line with standards, guidance and the law: • Pre-admission assessments were completed by the registered managers or provider before people moved into the home, to ensure their needs could be met. This included an assessment for any specific equipment that people may require. • Staff told us they knew people well, read care plans and got to know people's changing needs through good communication within the small staff team and by using daily records. • A range of well-known tools were used to monitor people's health and wellbeing in line with best practice guidance. For example, staff used nationally recognised tools to assess people's pain levels and risks of developing pressure injuries. • The service used technology to monitor people's general health and took action where appropriate. For example, a variety of health monitoring equipment was used as part of a 'telehealth' scheme in partnership with a local medical centre. With the consent of the person, trained staff used the equipment to take their observations, such as blood pressure, temperature and pulse, which could then be sent electronically to the medical centre. This enabled staff to identify any concerns promptly and highlight these to medical professionals immediately. Supporting people to eat and drink enough to maintain a balanced diet: • People were highly complementary of the food. People's comments included, "The food is excellent, the cooks are very good", "The food is good, no complaints there, lots of good choices" and, "We can make suggestions and have what we like." • During the inspection we found that all people's requests for drinks and snacks were acknowledged and these were provided in a timely way. Care records demonstrated people had choice and access to sufficient food and drink throughout the day and night. • Where people were at risk of poor nutrition and dehydration, plans were in place to monitor their needs closely and professionals were involved where required to support people and staff. • Individual dietary requirements were recorded in people's care plans and staff knew how to support people effectively and there likes and dislikes. • Menus were personalised to people's needs and preferences and people received a balanced diet. • Mealtimes were a sociable experience for people who chose to sit in the dining area. • People were supported to be independent and were provided with adapted cutlery and plates, where required to enable independence. • Where people were supported to eat, this was done in a relaxed and supportive manner. Adapting service, design, decoration to meet people's needs: • The home was calm, homely and people could move around freely. The environment had been designed 11 The Croft (RCH) Limited Inspection report 23 July 2019 and adapted to promote people's safety, independence and social inclusion. • People were given the opportunity to be involved in decoration and refurbishment around the home, such as choosing items of furniture, colour schemes and joining in with gardening. • Some decoration throughout the home supported people living with dementia or poor vision, which included signs on toilet and bathroom doors. Hand rails were in place within corridors and these were of contrasting colours to the walls, to assist people with a cognitive impairment. Flooring was suitable for people with mobility needs. • People's bedrooms had been decorated to their tastes, together with some of their furniture and important possessions. Supporting people to live healthier lives, access healthcare services and support; staff working with other agencies to provide consistent, effective, timely care: • Care records confirmed people were regularly seen by healthcare professionals including, doctors, nurses, dentists and chiropodists. • When people's needs changed, staff sought the support of health care professionals in a timely way to ensure the person got the right support. For example, when a person's weight had reduced, and they could no longer be weighed, records showed that advice and support had been requested from healthcare professionals. • People's psychological and emotional needs were understood by staff. Staff actively supported people to maintain wellbeing in this area and had researched different mental health conditions to help understand these. This allowed them to provide more effective and personalised care to people. • The service ensured that people received consistent and coordinated care if they were required to move between services; such as requiring a hospital stay. This was done by providing the receiving service with up to date and relevant documentation and a verbal handover. • New people to the service were offered the opportunity to have daily visits, prior to permanently moving in. Staff told us how this benefitted them by allowing them time to settle, getting to know their surroundings and meet with different staff. Staff received a comprehensive handover of their needs and preferences, to ensure they were supported appropriately. One staff member said, "If there is someone new coming in, we are given a briefing, so we can understand what their needs are, and then it's a matter of making them feel at home." • Staff had built a positive working relationship with external professionals to ensure people received joinedup care. A social care professional commented, "[The staff] are outstanding at information sharing and work collaboratively with me and the social care practitioners." 12 The Croft (RCH) Limited Inspection report 23 July 2019 Good Is the service caring? Our findings Caring – this means we looked for evidence that the service involved people and treated them with compassion, kindness, dignity and respect People were supported and treated with dignity and respect; and involved as partners in their care. Ensuring people are well treated and supported; respecting equality and diversity: • People told us they were supported by kind, caring and compassionate staff. Staff spoke with people respectfully, ensured they were at eye level and addressed them in the way they preferred. • Interactions between staff and people were natural and showed positive relationships had been developed. For example, when a person started to fall asleep at the dining table, a staff member discreetly offered to help them to lay down in their bedroom, where they knew they liked to spend their time and be more comfortable. • Staff joined in with group and individual activities and offered people support if required. Staff were considerate of people's interests and preferred topics of discussion and encouraged their participation in conversations. • Staff created a homely and friendly environment for people and we saw that people were relaxed in the company of staff. One person said, "Everyone gets on well here." A health care professional commented, "The home is always welcoming." • People's cultural and diversity needs had been assessed and were detailed within their care plans. This included people's needs in relation to their culture, religion, sexuality and gender preferences for staff support. One person told us, "Once a month, I have a visit from [a member of the church]. I have been told I can go to the church as well." • Staff completed training in equality and diversity and the registered manager and staff were committed to ensuring people's individual needs and choices were met. • The registered managers and staff worked hard to promote people's wellbeing, in a way which supported their emotional needs. For example, a 'wellbeing wall' displayed information to encourage positivity and participation in mental and physical health. Supporting people to express their views and be involved in making decisions about their care: • Staff showed a good awareness of people's individual needs, preferences and interests. Care files included information about people's life histories and their preferences. • People's communication needs were identified, recorded and highlighted in their care plans. This ensured that staff were aware of the best way to talk with people and present information. For example, one person's care plan described how staff should encourage the person to repeat back instructions, to clarify their understanding. • Staff provided people with choice and control in the way their care was delivered. Throughout the inspection, we observed people being given a variety of choices about what they would like to do and where they would like to spend time. This was done in a patient and attentive manner. A staff member described how they respected a person's choice when supported them to get dressed, they told us, "I usually pick out two lots of outfits for her, so she can then decide which pair of trousers and which top she wants to wear." 13 The Croft (RCH) Limited Inspection report 23 July 2019 • People's care plans contained information for staff to ensure they were consistently offered choice in all aspects of their daily routine. For example, one care plan said, "I get up at my own pace and time in the mornings." • The registered managers were aware of how to request the services of independent advocates if needed. Advocates can be used when people have been assessed to lack capacity under The Mental Capacity Act 2005 for a specific decision and have no-one else to act on their behalf. We saw examples in people's care plans where advocates had supported people to make choices about their care. Respecting and promoting people's privacy, dignity and independence: • Staff treated people with dignity and respect and provided compassionate support in an individualised way. Throughout the inspection we saw that staff took steps to protect people's privacy, such as knocking on their door before they entered. • We saw comments from a recent relative's survey, which praised the levels of dignity and care that their relatives received from staff. One comment stated, "The staff treat [my relative] with care and respect. They are consistently calm and attentive." • Staff described the action they took to protect people's dignity and privacy when supporting them with personal care, such as covering them with a towel and closing the door. A staff member commented, "I ask them what they would like help with and tell them everything I am doing. I use a towel or a blanket to cover them up." • People were supported to maintain their independence as much as possible in their daily routines. One staff member described how they encouraged people's independence when providing personal care; they commented, "Some people have complex needs which vary day to day, so I always encourage people as much as I can. I say to them, 'you try and give it a go', I don't take over." • Information in people's care records reminded staff of the importance of maintaining people's dignity in a way which they preferred. For example, one care plan guided staff on the language the person preferred them to use when referring to incontinence pads. 14 The Croft (RCH) Limited Inspection report 23 July 2019 Good Is the service responsive? Our findings Responsive – this means we looked for evidence that the service met people's needs People's needs were met through good organisation and delivery. Planning personalised care to meet people's needs, preferences, interests and give them choice and control: • People told us they received care that was met their needs in a person-centred way. One person said, "It's excellent here, the staff are really good. They give me advice and are helping me to reconnect with my family. I feel really well supported." • Assessments were completed before people moved into the service, to determine whether their needs could be met appropriately. These were used to develop detailed and person-centred care plans for each person. • Care plans contained clear guidance for staff about the level of support people needed with their personal care and daily routine. This took into account people's preferences and wishes around how they wished to receive support. Care plans were reviewed monthly and were updated appropriately where people's needs had changed. • Staff told us they knew people well and had a good understanding of their family history, individual personality, interests and preferences. This enabled them to engage effectively and provide meaningful, person centred care. Staff had access to key information about people's care needs and used this information to help ensure they supported people in line with their preferences. • Health and social care professionals commented positively on the standard of person-centred care being delivered. One health professional said, "The care is person centred and people's views are valued and respected." A social care professional said, "I find all the staff approachable and have an excellent understanding of the care that is required to my complex cases." • People had access to activities that were important to them and were supported to follow their interests. Many people living at the service were independent and able to engage in activities of their choosing, such as going out in the local community, attending day centres, playing games and watching television. • The service employed two activities coordinators and people were provided with a range of activities if they wished to participate. Activities included; visits from external entertainers, arts and crafts, pamper sessions, movie nights, games, exercises and music. One person said, "Oh yes, I love the activities. I do lots of art." A health professional commented, "There is always daily activities going on and planned activities are scheduled which is an asset to the carers, as it is a busy but relaxed environment." Improving care quality in response to complaints or concerns: • The service had a clear policy and procedure in place to deal with complaints appropriately. Information about how to raise a complaint was clearly displayed in the main reception area of the service, along with contact numbers for the local authority complaints team and CQC. • We viewed records of recent complaints. These had been investigated thoroughly and responded to promptly, in accordance with the provider's policy. The registered manager described how they used complaints to help identify learning and to improve the service. • The registered manager and staff regularly engaged with people and their families so that any low-level 15 The Croft (RCH) Limited Inspection report 23 July 2019 concerns could be addressed quickly. Feedback was sought through formal questionnaires and through daily conversations and observations of people. End of life care and support: • At the time of the inspection, nobody living at the service was receiving end of life care. • One of the registered manager's described how they had supported a person in the past towards the end of their life to ensure they received dignified care. We saw a letter from the person's relative, which praised the standard of care their loved one received from staff at The Croft during this time. • People's care plans did not contain information about their end of life choices, however, the registered manager reassured us that people's wishes and preferences would be discussed and respected should this be required. • The registered managers had attended a training before the inspection, where they had gained further information about advanced care planning. They told us they planned to use this learning to have further conversations with people about their end of life wishes and implement a tool to record this information. 16 The Croft (RCH) Limited Inspection report 23 July 2019 Requires Improvement Is the service well-led? Our findings Well-Led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture Governance arrangements, record keeping, and quality assurance was not robust to ensure high-quality care was consistently delivered. At our last inspection in May 2018, we identified a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had failed to maintain accurate and complete records in relation to carrying out the regulated activity and did not ensure their quality assurance processes remained effective. At this inspection, we found action had been taken and there was no longer a breach of this regulation, although some further improvement was still required. Managers and staff being clear about their roles; understanding quality performance, risks and regulatory requirements: • Quality assurance systems and audits had been developed to assess, monitor and improve the service. However, these were not always robust in certain areas of the service. For example, a monthly health and safety audit contained limited information and did not provide a full account of which areas had been checked within the service. This meant that evidence of compliance was not recorded, and areas for improvement were not identified accordingly. • Care plan audits were not completed in a consistent manner and did not clearly identify which people's care plans had been reviewed, or what actions were required following the audit check. Furthermore, they had not identified where people did not have a mental capacity assessment or best interest decision in place regarding specific aspects of their care. • The system used by the registered manager to monitor completion of staff training was not up to date and had not identified where some staff had not completed refreshers in training. • We discussed the auditing processes with the provider, who acknowledged where improvements needed to be made and showed us an audit which they had completed in the month prior to the inspection. They also explained where they had received support during reviews undertaken by the local authority and external professionals. Following the inspection, we received a detailed action plan which outlined where improvements were required across the service and what actions the provider planned to take. • Although we found plans for improvements had been made, further work was still required in some areas, as highlighted above and time was also needed to ensure that the new practices that had been implemented were embedded to ensure that improvements made were sustained. • Policies and procedures were in place to aid the smooth running of the service. For example, there were policies on safeguarding, whistleblowing, complaints and recruitment. • The registered manager understood their responsibilities and had notified CQC about all incidents, safeguarding concerns and events that were required. • Since the previous inspection, there had been changes to the management team of the service. Feedback we received highlighted that improvements had been made within the service following the changes in management. A visitor said, "It's really improved. People seen much happier and staff now spend more time 17 The Croft (RCH) Limited Inspection report 23 July 2019 with them." A health care professional commented, "The home has really worked hard over the last three years to improve the standard of care for their residents and improvements are noticeable." • The registered managers demonstrated an in-depth understanding of each person's needs and on often worked alongside care staff to provide people with support. One of the registered managers told us, "It's important for us to do regular shifts as we do the things they [staff] do. We wouldn't ever make them do something they we wouldn't." A staff member commented, "[The registered managers] work the floor so they always know what going on." • We received positive feedback from health and social care professionals about the registered managers. A social care professional commented, "The managers are available when I attend and will discuss any concerns. I can discuss the care plans that they are implementing with them and they will implement any changes that are discussed with the client." • The registered managers told us they felt supported by the provider, who visited the home regularly. They commented, "[The provider] is brilliant, she is very supportive and understanding." Staff told us they found the provider approachable and were confident to speak to them about any concerns. Planning and promoting person-centred, high-quality care and support with openness; and how the provider understands and acts on their duty of candour responsibility: • People told us they enjoyed living at The Croft and felt it was well run. A person told us, "I really can't knock it here" and another said, "I am very happy here." • There was an open and transparent culture within the home. The previous performance rating was displayed in the reception area of the service. • Staff felt well supported by the management team, which enabled them to deliver effective care and support. One staff member said, "The management are very open here. If there is something bothering you, you can speak to one of them." • People living at The Croft spoke positively and confidently about the management of the service. One person said, "They are great. They are there if I need them, no problem" and another said, "[Registered manager] is the best, he always listens to what I say." • The registered managers described the values of the service as 'respect, encouraging independence and being open and honest." They described examples of how they were supporting people to maintain and build up their life skills to become more independent, such as moving into a supported living accommodation. • Many people living at The Croft had a complex history. Throughout the inspection, it was clear that management and all staff were understanding and committed to providing care for each person in a person-centred manner, which took into account their health conditions and history. Engaging and involving people using the service, the public and staff: • The provider and registered managers sought feedback from people about the service in a range of ways, which included annual quality assurance surveys and one-to-one discussions. • Resident meetings and staff meetings were held regularly. Meetings were used to provide information, such as planned improvements to the environment, activity ideas and changes to the menu. Minutes were kept and showed that where issues or suggestions were raised, action was taken. For example, the service had implemented a 'You said, we did' board following resident's meetings. This displayed where people had raised suggestions and what action had been taken, such as arranging a film night each week. • Staff demonstrated a genuine passion for their roles and worked well as a team. They told us they enjoyed working at the Croft and felt valued. One staff member told us, "I love it. It's very down to earth here, we all work well together." Another staff member commented, "I definitely do [feel valued]. We always get a well done" and a third said, "We all help each other, we are very team led, there is no blame game." Continuous learning and improving care; working in partnership with others: 18 The Croft (RCH) Limited Inspection report 23 July 2019 • The provider and the registered managers worked with social care professionals, health care professionals and the local authority to develop the service and improve the quality of care provided. Staff followed guidance provided by external healthcare professionals to ensure people received good overall care. • The registered managers attended regular meetings and forums with the local authority and health and social care professionals. They also used training opportunities to enhance their understanding and implement best practice in the care sector. For example, the registered managers described their plans to implement new tools and documentation systems, which they learnt about at a recent training course. • Throughout the inspection, we saw examples of supporting people to receive a joined-up provision of care with different organisations and professionals. We received positive feedback from health and social care professionals. A social care professional commented, "[The Croft] is a good care provider who provides care for complex and enduring care, they attend all meetings and their input is invaluable. All the clients like living at the Croft and that in its self is a true testimony of the care that they provide." 19 The Croft (RCH) Limited Inspection report 23 July 2019