We inspected this service on 15 May 2018. The Croft (RCH) is a 'care home' registered to accommodate up to 21 people. 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. On the day of our inspection there were 17 people living at the service, including older people and adults living with a mental health condition.

Following our inspection in September 2016, where we identified concerns in respect of medicines management, quality assurance, recruitment and records we told the provider they must send us an action plan each month telling us what they were doing to ensure people received a safe and effective support which met their needs. The provider sent us monthly evidence. On our last inspection in March 2017 we found the provider had addressed these concerns and but these practices were not fully embedded into the service. Therefore, the service was rated Requires Improvement in Safe and Well-led domains and overall.

At this inspection we found the service remained Requires Improvement in Safe and Well-led domains and overall.

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 provider informed Care Quality Commission earlier this year that the registered manager left due to personal reasons and the service was managed in the interim by two acting managers who planned to register in due course.

At this inspection we found concerns about the records, the effectiveness of the quality assurance systems and the governance of the service. We identified that the provider’s own medicines audits were not always effective as these failed to identify issues that we found. The provider’s own quality assurance also did not identify concerns around water risk assessment and the lack or the records of the fire drills. We found some of the provider’s policies still needed updating and that the staff did not always follow the provider’s policy.

People’s medicines were administered and stored securely. However, we found concerns regarding stock keeping and we identified there were no protocols surroundings ‘as required’ medicines. We also found there was not always evidence available that environmental risks were managed safely. For example, there was no evidence that regular fire drills took place. We also found there was no system in place to assess and manage potential risks relating to water safety. Following our inspection we asked the provider to take action to address these concerns. The provider promptly responded and advised they were going to review and implement a new water safety policy and risk assessment.

People told us they were safe. Staff knew how to report safeguarding concerns and they were confident any concerns would be followed up by the management promptly. People’s care files contained individual risk assessments surrounding people’s well-being and individual conditions. Where people had been identified as at risk, management plans guided staff on how to keep the person safe and staff knew people’s needs well. People were supported by sufficient numbers of staff and received support in an unhurried manner. Staff had ongoing training and told us they were well supported.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and report on what we find. 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

This inspection took place on 2 March 2017 and was unannounced. The Croft provides accommodation and personal care for up to 21 people, including older people with dementia and younger adults with mental health needs, who do not require nursing care. There were 16 people living at the home when we visited.

The Croft did not have a registered manager, however the manager had commenced the process to register with the commission. 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.

At the last inspection in September 2016, we asked the provider to take action to make improvements in relation to areas of the service including medicines management, record keeping, risk assessment and care planning, ensuring people’s legal rights to make decisions were assured, recruitment procedures and infection control. We told the provider they must send us an action plan each month telling us what they were doing to ensure people received a safe and effective service which met their needs. Action plans have been received each month and show the manager has been working with a range of professionals to make the necessary improvements. Most areas have now been completed and the service is now embedding these in practice. The manager was aware of remaining action that is required such as ensuring the policies and procedures were up to date and a business continuity plan was in place.

The manager and provider were aware of key strengths and areas for development of the service. Quality assurance systems were in place using formal audits and through regular contact by the provider and manager with people, relatives and staff.

Care plans provided comprehensive information about how people wished to be cared for and staff were fully aware of people's individual care needs and preferences. Reviews of care involving people were conducted regularly. People had access to healthcare services and were referred to doctors and specialists when needed. Systems to manage medicines safely were in place although staff did not have individual information as to when ‘as required’ medicines should be administered.

People and external health and social care professionals were positive about the service people received. People were positive about meals and the support they received to ensure they had a nutritious diet. People were supported and encouraged to be as independent as possible and their dignity was promoted. Staff followed legislation designed to protect people’s rights and freedoms.

People felt safe and staff knew how to identify, prevent and report abuse. Legislation designed to protect people's legal rights was followed correctly. Staff offered people choices and respected their decisions. People were supported and encouraged to be as independent as possible and their dignity was promoted.

There were enough staff to meet people's needs. The recruitment process helped ensure staff were suitable for their role. Staff received appropriate training and were supported in their work. Staff worked well together, which created a relaxed and happy atmosphere that was reflected in people's care.

People were offered an extensive range of activities suited to their individual needs and interests providing both mental and physical stimulation.

People and relatives were able to complain or raise issues on a formal and informal basis with the manager and were confident these would be resolved. This contributed to an open culture within the home. Visitors were welcomed and there were good working relationships with external professionals.

Improvements had been made to the homes environment which was clean and safe for people. Plans were in place to deal with foreseeable eme

This inspection took place on 6 September 2016 and was unannounced. The home provides accommodation for up to 21 people with mental health needs. There were 18 people living at the home when we visited. Most bedrooms were for used for single occupancy and some had en-suite facilities. People had access to two lounge dining rooms, accessible bathrooms and there was also an accessible garden area.

At our previous comprehensive inspection in November 2015 we found the provider did not have an effective system to ensure the safe management of medicines and people’s legal rights had not always been assured when care was provided. At this inspection we found adequate action had not been taken or not maintained to ensure medicines were managed safely and additional concerns were identified regarding records and management quality monitoring systems were not robust.

The home did not have 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. The manager told us they were planning to register with CQC and initiated the process to do this soon after the inspection.

The management team had taken action to address immediate concerns when they took over the running of the home in May 2016 and were committed to rectifying the situation and ensuring people received a service which met their needs. The previous management team had left without notice and removed or deleted electronic records. There were limited formal quality assurance systems. This meant that whilst some areas of concern had been identified and action was planned other areas of concern had not been identified and people may not have received the care they required.

Many records relating to the safe organisation and running of the home were inadequate or not present. Staff shortages meant the manager had been working some care shifts. This impacted on their ability to undertake all of their management functions.

Medicines were not always managed effectively meaning that people had not always received all medicines as prescribed by their medical practitioner and their health needs were not being met. Although, staff were aware of people's individual care needs and preferences the care plans and related records of the care people had received were incomplete. They did not provide information about how people wished to be cared for, or how their health care needs should be met. The manager regularly worked with care staff providing informal monitoring of the care people received.

The recruitment process did not ensure that all necessary pre-employment checks had been completed to ensure staff were suitable for their role. Training for all staff was planned via an external training provider. Staff were not receiving formal supervision or appraisals although they had regular support from the manager who often worked directly with them.

People felt safe and staff knew how to identify, prevent and report abuse. Legislation designed to protect people's legal rights was informally followed although formal mental capacity, best interest and consent assessments had not been documented. This meant people’s legal rights may not be assured in respect of decisions made on their behalf. Staff offered people choices and respected their decisions. People were supported and encouraged to be as independent as possible and their dignity was promoted.

People and relatives were positive about the care people received. People were positive about meals and the support they received to ensure they had a nutritious diet.

People and relatives were able to complain or raise issues on a formal and informal basis with the manager and were confident these would be resolved. Visitors were welcome

During this inspection we looked at how the home ensured the environment was safe and suitable for people and what training and support staff received. This was because when we previously visited in May 2013 they were not compliant with these areas. Although we met people who were living at the home we did not discuss these aspects of the service with them.

We spoke with two members of staff including the person in charge at the time of the inspection. Staff told us there was a range of training provided and there were systems in place to ensure support was available. Formal appraisal and supervision procedures were now in place.

Adaptations to the environment had been made to ensure the safety and suitability of the environment for the people living there.

We spoke with 11 of the 20 people who were living at the home. With the exception of one person, all people were very happy with the way they were cared for. One person told us “staff are very attentive”. Another said, “I am very happy here, no complaints, no hassle, the carers bend over backwards for me, they genuinely care, I cannot fault the care”. A person told us the carers “take me out for tea which is enjoyable”. Another person told us “if they are short staffed the manager and deputy manager would always muck in and help with the caring duties”.

We spoke with care staff who were aware of how people should be supported, their individual likes and dislikes and the help they required. Staff stated they felt they had sufficient time to meet people’s needs. Staff also told us they had attended relevant training and had all the necessary equipment to care for people safely.

We spent time observing care in communal areas. We found people had positive experiences. We observed staff were courteous and respectful of people's views. Choices were offered and the care we observed corresponded with care plans and risk assessments viewed.

Staff were receiving training and were generally available to meet people's needs however, there was a need to implement plans for supervision and appraisals.Concerns about security and fire exits identified previously had not been addressed. A range of quality monitoring procedures were in place.

During this visit, we looked at arrangements that were in place to assess and support people with food and fluids, as these had previously been inadequate to meet the needs of people using the service. We found that following an assessment some care plans had been put in place. An action plan was in place for those people who had been identified as losing weight to support their nutritional needs. The procedure to manage people's medicines had been reviewed and the records for those people we viewed showed that they were receiving their medicines as prescribed. The recruitment process was not effective at the last inspection. We found that a revised recruitment process was now in place. This was being followed to ensure that staff had the appropriate checks prior to starting work. We found that sufficient action had been taken to ensure people received the care and support with their meals and medicines.

We spoke with six people who were living at the home. Some people were unable to tell us about their experiences due to their cognitive problems. We observed how people spent their time, the support they received from staff. We also spoke to a visiting healthcare professional and the staff.

People told us that they were treated with well and “it was all right” when asked about what it was like living at the home. We observed that the staff behaved in a respectful manner when speaking to people. A visiting healthcare professional told us that they visited one of the people regularly and found that they had settled at the home. We found that although initial assessments were completed, people care plans did not reflect their current needs and how these would be met. Where risks were identified such as falls, there were limited action plans to show how these would be effectively managed.

Healthcare professionals advice were sought and detailed guidance was provided to staff . These were not always followed by the staff which meant that people did not receive the care they needed. People were not always supported to be able to eat and drink sufficient amounts to meet their needs.

We found that the arrangements for the management of people’s medicines were not adequate and action was needed. There was not always adequate staff and staffing hours were eroded by non care duties. There was a lack effective system to monitor the quality and service delivery.

We spoke with some people who lived at the home but most were unable to give their opinions due to their cognitive disabilities. We also spent some time in the home’s main lounge observing people and the way they were cared for.

As there were no visitors when we were at the home the manager provided us with some contact details for relatives. We telephoned these relatives who gave us their opinions about the service their relatives received.

We also spoke with other professionals involved in the care of people. They stated that they had no concerns about how people’s health and care needs were met. Professionals were complimentary about the way the service met people’s physical and cognitive needs.

Everyone we spoke with confirmed that people’s privacy and dignity were maintained at all times and that people were able to make day to day decisions such as what time they got up and how and where they spent their time.

People said that they had no concerns about how their personal care needs were met. They also told us that if they were unwell then staff would contact a doctor for them. We were also told that staff were available when people needed them and knew what care they required.

We telephoned some relatives following our visit to the Croft. They did not raise any concerns about how health and personal care needs were met. They also said that they were kept informed about any concerns or changes.

We observed that people were enjoying their lunch time meal and those able to respond told us meals were good and that alternatives were provided.

Relatives we spoke with said that whenever they had been at the home at meal times food had looked appetising. One said that the person they visited got themselves up early each morning and was given a breakfast at that time and then another breakfast later in the morning. We were told people had gained weight since being at the Croft.

We did not specifically discuss safeguarding with people or visitors however they said they felt they were safe at the Croft.

Visitors said that they felt staff were available whenever their relatives needed assistance. They also said that staff were very pleasant and had the necessary time to meet people’s needs.

People and relatives said that if they had any concerns or complaints they would raise these. People said that when they had raised issues in the past the manager had taken their concerns seriously and had acted to resolve the problem. Nobody had any concerns when we spoke with them.

This inspection took place on 16 and 20 November 2015 and was unannounced. The home provides accommodation and personal care for up to 21 people, including some people living with dementia and some younger adults with mental health needs. There were 21 people living at the home when we visited.

At the time of our inspection a senior staff member had applied to be registered with CQC as the home’s registered manager. Their application was being processed. 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.

Medicines were stored securely but systems had not ensured all medicines were available to be administered as prescribed. Individual ‘as required’ guidance and formal pain assessment tools were not in use meaning there may be inconsistency in administration by different staff.

The recruitment process records showed all necessary pre-employment checks had not been completed for one new staff member. There were enough staff to meet people’s needs and contingency arrangements were in place to ensure staffing levels remained safe. Staff received appropriate training and were supported through the use of one to one supervision and appraisal.

Information about how legislation designed to protect people’s legal rights should be applied for individual people was not always present. Best interest meetings to make decisions on behalf of people who lacked the ability to make these decisions had not been formally recorded. Staff were offering people choices and respecting their decisions appropriately.

The Deprivation of Liberty Safeguards (DoLS) were applied correctly. DoLS provides a process by which a person can be deprived of their liberty when they do not have the capacity to make certain decisions and there is no other way to look after the person safely.

People felt safe and staff knew how to identify, prevent and report abuse. Plans were in place to deal with foreseeable emergencies. The home was well maintained with further pans to improve the environment agreed by the provider.

Care plans provided comprehensive information about how people wished to be cared for and staff were aware of people’s individual care needs. People had access to healthcare services and were referred to doctors and specialists when needed. Reviews of care involving people or relatives, where people lacked capacity, were conducted regularly.

People and their relatives were positive about the service they received. They praised the staff and care provided. People were also positive about meals and the support they received to ensure they had a nutritious diet. A range of varied activities was offered with people able to choose to attend or not.

People and their relatives were able to complain or raise issues on an informal basis with the manager and were confident these would be resolved. This contributed to an open culture within the home. Visitors were welcomed and there were good working relationships with external professionals. Staff worked well together which created a relaxed and happy atmosphere, which was reflected in people’s care.

The manager was aware of key strengths and areas for development of the service and there were continuing plans for the improvement of the environment. Quality assurance systems were largely informal. There was regular contact by the provider and manager with people, relatives and staff.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.