Clifford House Residential Care Home

We found the following examples of good practice.

Measures were in place to prevent relatives and friends, professionals and others visiting from spreading infection when visiting the service. These were effectively implemented during our visit to the home. The service had developed a visiting policy based on the national guidance. This had been adapted as national guidance changed. All visitors were screened for potential symptoms of COVID 19.

Prior to the recent outbreak, measures had been put into place to re-introduce visits from friends and family. Safe, socially distanced, visiting had initially been facilitated in the garden and more recently an internal visiting booth had been built. The booth had been built by a local builder, free of charge, after the registered manager had put out plea for help to the local community. The booth was accessed only from the garden and was not accessible to people using the service. All visits were carefully scheduled and included time in between each visit to allow for staff to clean the booth. Whilst visiting had been suspended during the recent outbreak, the registered manager was very aware of the emotional impact on people when they were not able to see their relatives and so they had ensured that people continued to have contact with their family members through the use of social media, video and telephone calls. They told us that reinstatement of visits would be carefully risk assessed.

Activities had been adapted to include more one to one activities as opposed to group activities and this was possible due to the higher staffing levels that the provider had put in place. Whilst the use of external entertainers was not able to take place, the registered manager had, on occasion, made arrangements for an external entertainer to perform to people from the visiting booth which had been well received.

Measures were in place to prevent people from spreading infection upon admission or readmission to the service from hospital or the community. Potential new admissions were tested for COVID 19 prior to admission and were then required to undergo isolation for a period of 14 days.

The registered manager had, wherever possible, implemented isolation, cohorting and zoning within the service during the recent outbreak. Staff were assigned to support specific people to avoid the risk of transmission and toilets and bathrooms were designated for specific groups of people. Where people did not understand the risks to them, or others, of not self isolating and maintaining social distance, measures to mitigate this risk were in place. For example, the provider had deployed increased staffing numbers to help ensure that they could be available to provide redirection and support to people and to regularly sanitise items equipment or furniture.

There were clear procedures in place for donning, doffing and disposal of personal protective equipment (PPE). Staff had been provided with additional uniforms and changed into these on arrival at the home, and changed out of these before leaving. They had each been given a kit bag made by a member of the local community to store their uniforms in.

The registered manager was able to describe the correct level of PPE required to be worn by staff when supporting people who were self-isolating, and in a range of different circumstances. We observed that staff were wearing the right level of PPE for the tasks being completed. They were all bare below the elbow and not wearing jewellery other than a plain band.

Additional PPE stations had been put in place around the home so that staff were quickly able to don, (put on) PPE. People had clinical waste bins in their rooms and this allowed staff to doff, (take off) their PPE as safely as possible. Staff all had their own individual hand sanitiser and wipes were readily available to wipe down equipment in between use.

The home continued to engage with the whole home testing programme for people and staff and including twice weekly rapid flow tests for all staff. People who used the service were having tests once a week, as well as twice daily temperature and oxygen saturation level checks.

The homes infection control policy was appropriate and there was a separate COVID 19 policy along with a contingency plan. The recent outbreak had resulted in a large number of staff being unable to work, the action taken by the provider had helped to ensure that the home had been able to continue operating. They had stepped in to run the service and were supported by the use of agency staff who were blocked booked and were only working at Clifford House and were subject to rapid flow tests at the start of their shift.

The home looked clean and hygienic. Routine cleaning schedules had been enhanced with increased cleaning of contact points, such as doors, handles, handrails, and light switches.

Higher staff levels continued to be deployed whilst both people and staff were fully recuperating after having been infected with COVID 19 which had made them more tired and lethargic that usual. Staff had put in place fluid charts to monitor people’s nutritional input more closely and people were being provided with additional encouragement and support at mealtimes.

The provider had ensured that staff who were self-isolating in line with government guidance received their normal wages whilst doing so and the wellbeing of staff was monitored by the registered manager.

Staff had received specific and ongoing training including infection prevention and control (IPC) and handwashing. The registered manager had appropriately liaised with relevant agencies such as Public Health England and the Clinical Commissioning Group. Their advice had been followed. They also took part in a care home forum with other registered managers which they had found supportive and which had promoted the sharing of ideas and learning. Staff utilised remote consultations with health care professionals where able.

Rating at last inspection: At the last inspection in April 2018, we rated the service as ‘Requires improvement’. That inspection identified two breaches of the Regulations. There had been a failure to ensure controlled drugs were managed in line with legal requirements and the governance systems had not been fully effective at assessing the safety and quality of the service.

People’s experience of using this service: Some of the risks associated with people’s care had not been consistently assessed and planned for. Some care plans still contained omissions or would benefit from being more detailed.

Improvements were needed to ensure that all of the required pre-employment checks took place.

Opportunities for organisation learning were not being maximised. The system for documenting and investigating incidents and other safety events needed to be more effective.

Improvements had been made to ensure that controlled drugs were managed in line with legal requirements.

There was a more comprehensive range of audits being undertaken and it was evident that these were beginning to drive improvements.

Systems and processes were in place to safeguard people from the risk of abuse.

The home was visibly clean, and staff followed appropriate infection control measures.

There were sufficient numbers of staff deployed to meet people’s needs. Staff received an induction and regular training opportunities to keep their knowledge up to date. There was an effective supervision programme in place.

People were offered choice and control over the care they received. Where there was doubt about people’s ability to make significant decisions about their care, mental capacity assessments had been completed to check whether people could consent to the care and support being provided.

Staff were using evidence-based practice and guidance to enhance the care provided.

People were supported to eat and drink and to maintain a balanced healthy diet.

A range of improvements had been made to the internal décor and to ensure that people had access to a pleasant, well maintained, albeit small, outdoor space.

Where necessary a range of healthcare professionals had been involved in supporting people to maintain good health.

People continued to be treated with kindness, respect and dignity. Staff understood the importance of supporting people to maintain their independence.

People and their relatives told us that a strength of the service was its friendliness, the relaxed and homely environment and the person-centred care provided.

A programme of activities was provided with people told us they enjoyed.

Information about how to complain was readily available within the service and people were confident they could raise concerns and that these would be listened to.

People were supported to live well until their death and to remain at Clifford House if this was their wish.

There was a clear leadership and management structure in place which helped to ensure that that staff at all levels were clear about their role and responsibilities.

People and their relatives had been asked to share their views about the quality of care they received, and we saw that people had opportunities to get involved in influencing their care and environment.

The registered manager had developed links with the local community and key organisations to benefit people living in the home and to help with the development of the service.

Why we inspected: This was a planned inspection based on the rating at the last inspection in April 2018.

Follow up: Going forward we will continue to monitor this service and plan to inspect in line with our re-inspection schedule for those services rated Good.

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

Clifford House is a ‘care home’. 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.

Clifford House is a small family owned residential care home located in a residential area of Andover. The home is arranged over two floors and can accommodate up to 21 people. At the time of our inspection there were 16 people living at the home. The home supports people with a range of needs. Some people were quite independent and only needed minimal assistance, whilst others were more dependent and needed assistance with most daily living requirements including support with managing their personal care and mobility needs. Some of the people being cared for in the home were living with dementia and could at times display behaviour which might challenge others.

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 and associated Regulations about how the service is run.

Following the last inspection, we asked the provider to complete an action plan to show what they would do, and by when, to improve the key questions, safe, effective, responsive and well led to at least good. Some of the required actions had been completed. For example, improvements had been made to ensure that people were protected from risks associated with the environment. Risks to people’s health and safety were now being more robustly assessed and plans were in place to mitigate these risks.

Improvements had been made to ensure that people’s care plans fully reflected their needs.

The provider was now undertaking all of the required checks before staff started working at the service and improvements had been made to ensure the home was clean throughout.

However, we found continuing concerns with regards to how medicines were being managed. In addition, whilst improvements had been made to the governance arrangements within the service, these were still not being fully effective at identifying areas where safety was compromised, or to ensure compliance with the Regulations.

There had been an improvement with the frequency of supervision but this needed to be embedded and sustained. Appraisals had not yet taken place for all staff.

Staff were providing people with increased opportunities for meaningful interaction, but some people felt more could still be done to offer a greater range of activities. We have also made a recommendation about developing the activities provided to people living with dementia.

Other areas remained good. There were sufficient numbers of staff deployed to meet people’s needs.

Staff had received training in safeguarding adults, had a good understanding of the signs of abuse and neglect and knew how to report any concerns.

Staff acted in accordance with the principles of the Mental Capacity Act 2005.

People told us they enjoyed the food provided and staff were well informed about their dietary requirements.

The home had continued to work effectively with a number of health care professionals to ensure that people received co-ordinated care, treatment and support.

Staff were kind and caring in their interactions with people and treated them with dignity and respect. Staff knew people well, and about the things that were important to them.

People knew how to make a complaint and information about the complaints procedure was included in the service user guide.

Everyone spoke positively about the registered manager and the friendly and homely culture within the home.

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 the report.

Clifford House is a small family owned residential care home located in a residential area of Andover. The home is arranged over two floors and can accommodate up to 21 people. At the time of our inspection there were 20 people living at the home. The home supports people with a range of needs. Some people were quite independent and only needed minimal assistance. Others were more dependent and needed assistance with most daily living requirements including support with managing their personal care and mobility needs. Some of the people being cared for in the home were living with dementia and could at times display behaviour which challenged others.

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 and associated Regulations about how the service is run. The registered manager was also the registered provider. For the last 12 months, the registered manager had not been providing day to day management of the service but had instead appointed a manager to perform this role. The manager had been appointed in October 2016, but had not yet submitted an application to the Care Quality Commission to become the registered manager.

People had not always been protected from risks associated with the environment.

The provider had not taken proper steps to ensure that all of the required checks had been completed before staff started working at the service.

Improvements to the cleanliness of the home were needed.

Medicines were not always managed safely. We could not be confident that people were receiving their medicines as prescribed.

The provider had not adequately assessed risks to people’s health and safety and done all that was reasonably practicable to mitigate such risks.

Changes to people’s needs had not always been effectively communicated within the staff team.

Improvements were needed to the governance arrangements within the service. The provider and manager did not operate a robust programme of audit and checks to ensure the safety and quality of the service was being maintained.

Records were not available which demonstrated that staff had received an appropriate induction, supervision and an appraisal.

More needed to be done to ensure that staff provided people with increased opportunities for meaningful interaction.

There were sufficient numbers of staff deployed to meet people’s needs.

Staff had received training in safeguarding adults, had a good understanding of the signs of abuse and neglect and knew how to report any concerns.

Staff acted in accordance with the principles of the Mental Capacity Act 2005. Where people's liberty or freedoms were at risk of being restricted, the proper authorisations were in place or had been applied for.

People told us they enjoyed the food provided and staff were informed about whether people were nutritionally at risk and measures put in place to address any risks.

The home worked effectively with a number of health care professionals to ensure that people received co-ordinated care, treatment and support.

Staff were kind and caring in their interactions with people and treated them with dignity and respect?

People and their relatives were involved in making decisions and planning their care.

People knew how to make a complaint and information about the complaints procedure was included in the service user guide.

Everyone spoke positively about the manager and the friendly and homely culture within the home.

We found three 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 the report.

Clifford House is a care home which provides residential care for up to 20 older people living with a range of medical conditions including diabetes and those living with epilepsy and Dementia.

The care home comprises of two floors situated within its own secure grounds and garden in a residential area on the outskirts of Andover town centre. The home has 20 rooms, a communal lounge and dining room with television, bathrooms and a small sitting area in the back garden with furniture for people, relatives and visitors to enjoy. Meals were served at people’s choice in their rooms, lounge or dining room. At the time of the inspection 16 people were living at the home.

Clifford House has a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 registered manager was not present at the home during the inspection but was available to be spoken and communicated with during this time. Throughout this report care staff will be referred to as ‘staff’.

The provider did not ensure that accurate records were in place to ensure there were sufficient staff deployed to ensure that people’s individual needs were met in a timely fashion. The provider had not ensured that regular reviews of people’s dependency needs were carried out to identify the correct number of staff required to meet people’s needs.

The home did not always ensure that people living with dementia had appropriate opportunities to participate in meaningful activities to ensure they led a full and active life. We have made a recommendation that more activities for those living with dementia are made available to people.

Contingency plans were not in place prior to the inspection to ensure the safe delivery of people’s care in the event of adverse situations such as a fire. This was brought to the registered manager’s attention during the inspection and a detailed plan was then created. Fire drills were documented, understood by staff and practiced to ensure people were kept safe. However staff did not know what practices were in place to ensure people received a continuity of care in the event of an on-going adverse situation such as fire or flood which meant the home was inhabitable.

The provider had not always ensured that actions resulting from quality control audits had been completed in order to improve the quality of the service provided. The registered manager had not always taken steps to address these and ensured that appropriate actions were taken.

Care plans and associated paperwork were not always accurately updated when people’s needs changes so healthcare professionals would be able to provide the care people needed when away from the home.

Relatives and people told us they felt that the registered manager was not always a visible presence in the home. Staff told us they felt supported by their colleagues and senior staff however they did not always feel this support from the registered manager.

Relatives of people using the service told us they felt their family members were kept safe. Staff understood and followed guidance to enable them to recognise and address any safeguarding concerns about people. People’s safety was promoted because risks that may cause them harm had been identified and guidance provided to manage these appropriately. People were assisted by staff who encouraged them to remain independent. Appropriate risk assessments were in place to keep people safe.

Recruitment procedures were completed to ensure people were protected from the employment of unsuitable staff.

People were protected from the unsafe administration of medicines. Senior staff responsible for administering medicines had received training to ensure people’s medicines were administered, stored and disposed of correctly. Staff skills in medicines management however were not regularly reviewed by the registered manager to ensure staff remained competent to administer people’s medicines safely.

Care plans contained detailed information to assist staff to provide care in a manner that respected each person’s individual requirements and promoted treating people with dignity. People were encouraged and supported by staff to make choices about their care including how they spent their day either in the home or supported at external activities.

People, where possible, were supported by staff to make their own decisions. Staff were able to demonstrate that they complied with the requirements of the Mental Capacity Act 2005 when supporting people. This involved making decisions in the best interests of people who lacked the capacity to make a specific decision for themselves. Staff sought people’s consent before delivering their care and support. Documentation showed people’s decisions to receive care had been appropriately assessed, respected and documented.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The registered manager showed an understanding of what constituted a deprivation of a person’s liberty. Appropriate applications had been made to the relevant supervisory bodies to ensure people were not being unlawfully restricted.

People were supported to eat and drink safely whilst maintaining their dignity and independence. We saw that people were able to choose their meals and they enjoyed what was provided. Records showed people’s food and drink preferences were documented in their support plans and were understood by staff. People were supported to eat and drink enough to maintain a balanced diet.

Relatives we spoke with knew how to complain and told us they would do so if required. When complaints had been made these had been successfully resolved to the relatives satisfaction. Procedures were in place for the registered manager to monitor, investigate and respond to complaints in an effective way. People, relatives and health/social care professionals were encouraged to provide feedback on the quality of the service during annual questionnaire quality survey questionnaires.

The registered manager promoted a culture which focused on people receiving compassionate and kind care from accessible staff. People were assisted by staff who encouraged people to express their views and feel comfortable to raise concerns with them and the registered manager. The provider routinely and regularly monitored the quality of the service being provided.

Staff were not able to identify the provider’s values of care delivery. However we saw these standards of care including staff being approachable, kind and caring were evidenced in the way that care was delivered to people.

The registered manager had fulfilled the legal requirements associated with their role. The registered manager had informed the CQC of notifiable incidents which occurred at the service allowing the CQC to monitor that appropriate action was taken to keep people safe.

We found a breach 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 the report.

On the day of the inspection there were 20 people living at the home.

This is a summary of what we found '

Is the service safe?

The provider had taken action to help ensure that people who use the service were safe by the maintenance of an accurate record of the care and treatment they received. People's care records were kept securely, but readily available to staff when required.

Overall, care plans and other records were accurate and fit for purpose. Charts used to monitor aspects of people's personal care tasks had mostly been fully completed. Arrangements were now in place to document weekly blood sugar checks and people's fluid intake where these were required. We did note that the forms used for recording this information could be improved to help ensure that staff had sufficient guidance to enable them to effectively respond to fluctuations in blood sugar readings.

The application of topical medicines was being recorded on a topical medicines administration record (TMAR). Topical medicines are creams or lotions which are applied to the body to treat skin conditions. We did see a small number of examples where the application of a person's creams had still only been recorded in their daily records. Therefore the use of a TMAR needs to be embedded in practice and sustained to ensure that these are an accurate record of the topical medicines people receive.

The home has a registered manager who is also the registered provider of the service. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service and shares the legal responsibility of meeting the requirements of the law alongside the provider.

During the inspection we spoke with six people who use the service. Where people were unable to speak with us due to their complex needs, we used other methods to help us understand their experiences including observation of their support. We spoke with a number of staff including the registered manager, and three care workers. We reviewed 10 people's care and support plans and other relevant records.

We had previously assessed that Clifford House Residential Care Home had not been meeting six of the essential standards. This inspection, reviewed whether they had taken action and made the required improvements to comply with these standards. In addition, we also reviewed whether the service was meeting the essential standards in relation to records and the management of medicines.

We gathered evidence against the outcomes we inspected to help us answer our five key questions.

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

Below is a summary of what we found. If you want to see the evidence supporting our summary please read our full report.

Is the service safe?

People living at Clifford House told us that they felt safe. Safeguarding procedures were in place and staff understood how to safeguard the people they supported.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Whilst no-one living at the service was currently subject to a DoLS, we found that the manager understood when an application should be made and how to submit one and was aware of a recent Supreme Court Judgement which widened and clarified the definition of a deprivation of liberty.

We found that some people's care records contained incomplete monitoring charts which meant that accurate monitoring of their needs would be difficult. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the maintenance of accurate and appropriate records to ensure that people are fully protected against the risks of unsafe or inappropriate care.

Is the service effective?

Before people received care, they were asked for their consent and care staff acted in accordance with their wishes. The manager was knowledgeable about the Mental Capacity Act (MCA) 2005 and was able to demonstrate an understanding of assessing people's capacity to make decisions. Care staff displayed knowledge of the key principles of the MCA and we saw records which showed that all staff had completed training in the MCA.

People's care plans included information about the care and support they needed. Staff we spoke with were informed about people's needs and were able to tell us about the care they provided.

The provider had made arrangements to ensure that a programme of repair and on-going improvement was maintained within the service, which ensured that people were protected against the risks of unsafe premises and were cared for within a comfortable and pleasant environment.

The provider had put in place arrangements to provide staff with supervision and appraisals. Whilst we found that improvements had been made to the frequency of supervision, and staff told us that they felt well supported, these improvements will need to be embedded in practice and sustained to ensure that they were a fully effective tool in supporting the development of staff.

Is the service caring?

People we spoke with were positive about their care and the support they received from staff. One person said, 'The staff are very kind, they always go out of their way, no-one could complain'. Another person said, 'You come here, you come home, you belong'. A third person said, 'They [staff] are kind and caring'.

People's preferences, likes and dislikes had been recorded and we saw that support was provided in accordance with people's wishes.

Is the service responsive?

The service had measures in place to review people's needs on a regular basis. We saw that action was taken in response to any changes in people's needs. For example, we saw that one person was referred to their GP when they developed signs or symptoms of a urine infection. Another person had been referred for a continence assessment and a GP had been consulted about a third person's skin complaint. This meant that the service worked effectively with other providers to ensure that people received co-ordinated care, treatment and support.

Systems were in place to ensure that the service learnt from incidents and accidents, comments and complaints.

Is the service well led?

There were arrangements in place to ensure that people who use the service, their representatives and staff were asked their views about the care the service provided. We saw that where the need for improvement was identified, the service was taking action to address this.

The service had taken action to ensure that it had quality assurance systems in place to assess the quality of the service and identify where improvements could be made. However some of these needed to be further embedded to ensure that they provided an effective system for monitoring the quality and safety of the service people received. For example, some of the care records at the home were not clear or incomplete. These issues had not been identified through the audit process.

During our inspection on 27 November 2013, we found that the service had not protected people against the risks associated with unsafe premises. As a result of that inspection, we served the provider with a warning notice in relation to the safety and suitability of the premises with a requirement that they become compliant by 31 January 2013. On the 25 February 2014 we carried out a follow-up inspection to check whether the home had become compliant.

Prior to the inspection on 25 February 2014, we had become aware of concerns that staffing levels within the home might at times be impacting upon the ability of staff to provide person centred care and enable people to express choice about how and when their needs were met. Therefore this inspection also looked at whether the provider had ensured that there were adequate numbers of suitably qualified staff on duty at all times.

We found that the home had made some improvements to the safety of the premises since we last inspected. Work had been completed to secure the windows in order to ensure that the home maintained a safe environment for vulnerable people. Equipment had been installed to assist in maintaining safe water temperatures to prevent the risk of scalding to people who used the service. However, work to ensure effective legionella control and monitoring was in progress but had not been fully completed.

People told us that there were sufficient number of care workers to meet their needs and that staff responded promptly to call bells or requests for assistance. We found that the provider had arrangements in place to respond to changing circumstances in the service, for example to cover staff sickness or absence.

However, there were not adequate arrangements in place to make sure staff acted in accordance with legal requirements where people who used the service did not have capacity to consent to their care and treatment. Adequate arrangements were not in place for ensuring that the service took account of the requirements of the Mental Capacity Act 2005 Deprivation of Liberty Safeguards. We observed that the care plans did not always provide sufficient detail about key risks to a person's health and welfare and how these should be managed.

We found that people might not always be protected from abuse as staff did not have up to date safeguarding training. Key risks associated with the premises had not been identified including inadequate water safety checks and the risk of falls from unrestricted windows on the upper floor. We also found that the quality monitoring arrangements were not sufficiently robust.

We found that the needs and risks of people using the service had been assessed. Care plans were in place for everyone receiving personal care and these had been reviewed in line with the provider's policy. Staff had had access to good training and were competent in their caring role. However there were some gaps in terms of continual supervision and professional development. Safeguarding procedures were in place and staff knew how to report suspected abuse. There was scope to improve the risk assessment process around malnutrition and skin integrity in order to ensure that preventative measures were used to maximum effect.