Clifton House Residential Care Home

Clifton House Residential Care Home provides accommodation and personal care for up to 28 people, some of whom are living with dementia. At the time of the inspection there were 23 people living in the home.

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

People were safe living in the home. We observed positive interactions between staff and people, and they communicated with ease and familiarity. Staff were passionate about their roles and of the people they supported. One staff member said, “I love working at Clifton house. Our residents are at the forefront of our philosophy of care. Our residents are our second family and are always treated with compassion, dignity, and respect.”

People were safeguarded from abuse. Risks to the environment were well managed. The registered manager learned from accidents and incidents to mitigate future risks. Infection prevention and control processes were embedded into the service and staff followed government guidance in relation to infection control and prevention practices, in particular, relating to COVID-19. A health professional told us, “It’s a nice clean and tidy home. All Infection Prevention and Control (IPC) practice is adhered to and they have always followed the government guidance by the book.”

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

Staff supported people with their social needs and to maintain relationships that were important to them.

The home was well managed. People, staff and health professionals were complimentary about the home and felt the registered manager was pro-active, open and approachable. In a recent survey a health professional stated, “There aren’t any areas for improvement as this is an excellent care home with very caring and professional staff.” An effective quality assurance process was in place.

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

Rating at last inspection

The last rating for this service was good (published 27 February 2019).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We undertook this targeted inspection to follow up on specific concerns we had about the service about safeguarding, health and safety of the service, people’s social needs, governance and overall management of the home. A decision was made for us to inspect and examine those risks.

CQC have introduced targeted inspections to follow up on warning notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the Safe, Responsive and Well-Led sections of this full report.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

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

Follow up

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

Clifton House provides personal care for up to 28 people; nursing care is not provided. At the time of our inspection there were 22 people living at the home who received personal care, some of whom were living with a dementia.

People’s experience of using this service:

People told us they received safe care. Medicines were managed safely. Staff followed infection prevention and control guidelines. Potential risks to people were assessed and managed appropriately. Safe recruitment procedures were in place.

Staff sought people's consent before providing care and support. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice. Staff training in key areas was up to date.

People were treated with kindness and compassion. Staff respected people's privacy and dignity and people were supported to be as independent as possible. Staff had built positive and caring relationships with people and their families.

People received personalised care that was responsive to their needs and preferences. It was clear from our conversations with staff they knew people’s needs well. People and relatives knew how to make a complaint, although nobody we spoke with had any.

There were effective systems in place to monitor the quality of the care provided. The registered manager and deputy manager had made significant improvements throughout the service. People’s feedback was sought regularly and acted upon. We received positive feedback about how the service was managed.

More information is in the detailed findings below.

Rating at last inspection:

Requires improvement (report published 14 February 2018).

Why we inspected:

This was a planned inspection based on the previous rating.

Follow up:

We will monitor all intelligence received about the service to inform the assessment of the risk profile of the service and to ensure the next planned inspection is scheduled accordingly.

Clifton House is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Clifton House provides personal care for up to 28 people. At the time of our inspection there were 16 people living at the home who received personal care, some of whom were living with dementia.

A registered manager was not in place at the time of our inspection. However, a manager had been in post since May 2017 and was applying to register with the Commission to be a registered manager. 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.

We last inspected this service on 31 October and 7 November 2016 when it was rated 'Requires Improvement' overall. During this inspection, although we found further improvements had been made, some improvements were still needed so the rating remains ‘Requires Improvement' overall.

We have made a recommendation about visits from the provider and how the provider acts on people's feedback.

Although the premises were clean, comfortable and free of odours, some areas of the service looked worn and needed renovating. A refurbishment programme was in place for the coming year to address this.

People we spoke with said they felt safe living at Clifton House. Staff had completed training in safeguarding vulnerable adults and understood their responsibilities to report any concerns.

Risk assessments relating to people's individual care needs and the environment were reviewed regularly. Regular planned and preventative maintenance checks and repairs were carried out and other required inspections and services such as gas safety were up to date.

Accidents and incidents were recorded accurately and analysed regularly. Each person had an up to date personal emergency evacuation plan should they need to be evacuated in the event of an emergency.

Staff received regular supervisions and appraisals and told us they felt well supported by the manager. Staff training in key areas was up to date.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People were supported to have enough to eat and drink and attend appointments with healthcare professionals.

There was a welcoming and homely atmosphere at the service. People were at ease with staff. People and relatives said staff were caring. Staff treated people with kindness and compassion.

Each person who used the service was given information about how to make a complaint and how to access advocacy services. An advocate is someone who represents and acts on a person's behalf, and helps them make decisions.

Staff had a clear understanding of people's needs and how they liked to be supported. People's independence was encouraged without unnecessary risks to their safety. Support plans were well written and specific to people's individual needs.

People and relatives we spoke with knew how to make a complaint. They told us they would speak to a member of staff or the manager if they had any issues.

People, relatives and staff spoke positively about the manager. Staff described the registered manager as approachable. Teamwork and communication sharing were prominent and staff had various opportunities to provide feedback about the service.

Clifton House Residential Care Home is registered to provide nursing or personal care for up to 28 people. At the time of our inspection there were 16 people living at the home, some of whom were living with dementia.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Since our last inspection the provider had made progress to improve the quality and safety of people’s care.

People and relatives felt the home provided good care. People were cared for by caring, kind and considerate care workers who treated people with dignity and respect. People were supported to make choices and decisions so that they felt in control of their care.

People said they felt safe living at the home. Care workers had completed training in safeguarding and their knowledge was checked periodically.

Improvements had been made to ensure there were enough care workers on duty to meet people’s needs in a timely manner. There was evidence available to show the missing premises checks found during the last inspection had been completed. However, we found no record of in-house fire instruction or fire drills for night time care workers.

Further improvements were required to the recruitment processes in the home. We found some gaps in the pre-employment checks of some care workers. References and DBS checks had been completed before new care workers started their employment.

We found some minor issues with the management of medicines. Care workers did not consistently record the date bottled medicines had been opened. The guidance care workers followed when administering ‘when required’ medicines was unclear. Records confirmed medicines were administered and stored appropriately.

We found some premises shortfalls requiring attention, such as the outside laundry building was very dusty and the use of free standing radiators in the conservatory.

Risks assessments were carried out to minimise risks to people’s safety. Assessments clearly detailed the measures required to help keep people safe. We saw care workers followed safe procedures when assisting people to mobilise.

Support for care workers was an area of on-going development. The registered manager had started to carry out annual appraisals of care workers' performance. Some had been completed and others planned in. A supervision plan had been developed to ensure all care workers had regular one to one supervision with a manger. Care workers had completed training in moving and assisting, first aid and basic life support. Care workers were also completing specific ‘dementia focus’ training. New care workers were required to complete the Care Certificate.

The provider followed the requirements of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS). DoLS applications had been authorised for relevant people. Specific care plans had been written to help care workers support people with decision making.

Improvements had been made to people’s meal time experience to ensure they received the required support and assistance to meet their nutritional needs.

People had input from a range of health professionals, such as GPs, dentists, opticians, and dietitians.

Care plans were personalised to help guide care workers on the individual care people needed. This included details of people’s preferences, such as food likes and dislikes and preferred routines.

People’s needs had been reassessed and care plans had been updated to reflect people’s current needs. Care plans had been evaluated to help ensure they remained relevant. People and sometimes family members were involved in reviewing the care provided. Positive feedback from relatives about people’s care had been noted.

Where people needed assistance we saw care workers responded quickly. For example, when people appeared cold, uncomfortable or required a drink.

There were regular activities for people to take part in. These included card games, exercises, one to one time and cooking activities.

The provider held ‘residents’ meetings’ to allow people the opportunity to meet and share their views. Following consultation with people plans were underway to convert a little used room into a movie room.

People knew how to complain if they were unhappy with their care. Previous complaints had been investigated with appropriate action taken to investigate and resolve each issue.

The provider was working through a detailed improvement plan which had been developed to address the concerns identified during our last inspection. This included improving the effectiveness of the quality assurance procedures.

The previous registered manager had retired and a new registered manager had been appointed. Relatives and care workers gave is positive feedback about the new manager.

People and care workers had given positive feedback during recent consultation. People had described care workers as lovely, caring, friendly and courteous.

The manager completed monthly management checks of the home looking at areas such as health and safety, medicines, staffing, finances. An action plan was developed each month to help ensure any areas for improvement were identified and completed.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Clifton House Residential Care Home is registered to provide nursing or personal care for up to 28 people. At the time of our inspection there were 25 people living at the home, some of whom were living with dementia.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During this inspection we found the registered provider had breached regulations 9, 17, 18 and 19 of the Health and Social Care Act 2008. We found there were not always enough staff deployed to ensure people received the care they needed in a timely manner. Staff had not received regular one to one supervision with their line manager. Some training and appraisals were also overdue for all staff. The registered provider had not followed safe procedures when recruiting new staff to ensure they were suitable to work with vulnerable adults. People living with dementia did not always receive personalised care to meet their specific needs. In particular, staff had not completed in-depth training in dementia awareness and adaptations had not been made to help promote people’s independence. There was a lack of meaningful engagement and stimulation for people with no activities being provided. The environment was not suitable for people living with dementia. Needs assessments and care plans had been completed without the involvement of people using the service or family members who knew them well. Care plan evaluations were overdue for all care plans that we viewed. Opportunities for people or family members to give their views had lapsed. Audits and checks to ensure people received safe and appropriate care were overdue. This included analysing falls in the home, which had increased since January 2016.

You can see what action we have asked the provider to take at the back of the full version of this report.

We found during this inspection the registered provider had met the requirements of the warning notice issued following our last inspection. We viewed a sample of medicines administration records (MARs) and topical cream charts. We saw these were usually completed accurately with only minor gaps in signatures identified. Stocks of medicines were kept securely and safely in locked medicines cupboards and trolleys.

People and family members gave us good feedback about how kind, caring and considerate the staff team were. They said staff tried their best to meet their preferences, however this was currently difficult due to the current staffing situation within the home. Where people did receive interaction from staff this was always done with affection and kindness.

Staff had a good understanding of safeguarding adults and whistle blowing, including how to report concerns. They said they would feel able to raise concerns. One staff member said, “Yes I would raise concerns.” Safeguarding referrals had been made to the local authority safeguarding team in line with the home’s agreed safeguarding procedure.

Records showed some health and safety checks were not up to date, such as the fire risk assessment, fire drills, legionella survey and the electrical installation safety certificate. However, the registered manager told us these had been updated. Other checks were up to date including checks of gas safety, fire detectors and fire alarms. Personal emergency evacuation plans (PEEPs) had been completed for each person.

Although the home was clean, we saw there was unfinished maintenance work around the home which had been marked with large white crosses. The registered manager told us the maintenance person was catching up with the outstanding work.

The registered provider followed the requirements of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS). Applications for DoLS authorisations had been made to the local authority where required. Staff asked people for their permission before providing care.

We observed over the lunch time and saw people were regularly left unsupervised as staff were busy. Although most people were independent with eating and drinking, those people requiring support did not always receive this in a timely manner.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The provider had made progress with the assurances given in the action plan they sent us following our last inspection in April 2014. We found that changes had been implemented, including additional staff resources, to ensure people had an improved experience at tea-time. We also found that people received regular interaction from staff at other times of the day.

The provider had introduced regular care plan audits so that people's care records were completed accurately. We checked the care records for three of the 15 people who used the service and found that these had been completed appropriately.

We found gaps in medication administration records (MARs) for eight people who used the service. The provider did not have an effective system of medication audits to ensure that gaps in records were identified and investigated in a timely manner.

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led? Below is a summary of what we found.

The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report. This is a summary of what we found:

Is the service safe?

Where staff had identified a potential risk, either during the initial assessment or after admission, a risk assessment had been completed to ensure people remained safe. We found the provider assessed people, using recognised tools, against a range of potential risks. For example, the risks of poor nutrition, skin damage and falls.

The provider had systems in place to ensure people received their medication safely and in a timely manner, by trained and competent staff. People we spoke with, and family members, confirmed that they received their medication when it was due.

At times, particularly in the afternoon and at tea-time, staffing levels were inadequate to meet people's care and welfare needs appropriately. People we spoke with were positive about the staff providing their care. They said they felt there was enough staff to meet their needs. One person said, 'There are enough staff and they see to me quickly.' Another person said, 'The staff are very good, they go above and beyond what they are meant to do.' Some family members we spoke with said they felt a couple of additional staff were needed as staff appeared to be rushed off their feet.

Is the service effective?

We found that people who were able to sign had signed their care plans to give valid consent to their care and consent was reviewed periodically to ensure it remained valid. People confirmed that staff always asked them for permission before delivering any care. One person said, 'I am always asked first, I can do what I want.' Another person said, 'I can please myself what I do, no pressure.'

Is the service caring?

We observed care being delivered throughout our inspection as well as undertaking a specific observation over the tea-time period. We saw that staff followed the guidance within people's care plans, for example when undertaking moving and handling. We found that staff interacted positively with people and were attentive, kind and caring. Although we observed over the tea-time that sometimes people had to wait for long periods of time before receiving help, when they received this help it was positive and caring.

Family members confirmed that staff treated their relative not only with dignity and respect but also with affection. One family member commented, 'The staff are very considerate, efficient and have a friendly manner, very good.' Another family member said, 'The staff are lovely.'

Is the service responsive?

We found that care plans were evaluated each month to ensure they remained up to date and reflected people's current needs. We saw from viewing care records that staff had taken action to respond to people's changing needs, such as referring people to various health professionals for advice and guidance, including specialist nurses, speech and language therapists and dietitians.

Is the service well-led?

We found the provider did not have a systematic approach to quality audits in order to identify gaps in care records, including medication records, and ensure action was taken to address these gaps.

Relevant information, such as details of incidents, accidents, complaints and feedback from residents' consultation, was not analysed and used as a tool to promote learning and improve the care people received.

Feedback from the most recent consultation with residents and relatives was mostly positive. We saw that there had been 11 responses and people's satisfaction was rated as either 'quite satisfied' or 'very satisfied.'

The provider had systems to log and investigate any complaints received. We saw from viewing the complaints log they had not received any formal complaints in the previous 12 months.

People we spoke with told us they knew how to complain if they were unhappy with any aspect of their care and welfare. One person said, 'I would report any concerns if I had any.' Another person said, 'I have no concerns.' Family members had no complaints or concerns about their relative's care. Family members said: 'The staff are very approachable', and, 'The manager is very good and caring.'

We did not find evidence that staffing levels were reviewed or analysed on a regular basis, considering other factors that impact on staffing levels like dependency levels, to ensure that sufficient staff were available throughout the day.

We found people experienced care, treatment and support that met their needs and protected their rights. People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

We found that where people did not have capacity to consent, formal assessments were not undertaken to ensure that the provider acted in accordance with legal requirements.

People who use the service, staff and visitors were protected against the risks of usafe or unsuitable premises.

We spoke with three people who lived at the home. One person told us, "It's marvellous, I have everything that I need from a comfy room with my own television and lots of reading materials. The mobile library comes every week and leaves me a bag of books. The staff are very good and the attention that they give me really is marvellous". Another person living at the home told us, "I have no issues and I am very happy here, I came here twice for respite before moving in so would not have come back if it was not good". One person also told us, "It's great really you couldn't fault it".

Most of the people we spoke with were happy with the food and drinks provided by the service although there were some areas for improvement suggested by one person who used the service and one relative.

People received enough food and drinks to meet their needs and ensure they were well nourished and hydrated.

Clifton House ensured that people received the care and support they needed and involved health professionals when they were needed. People's welfare was maintained.

The provider had made sure that staff had received training about safeguarding vulnerable adults. Some staff we spoke with were not confident about what safeguarding was, however all staff were aware of their responsibilities if they witnessed any possible abuse.

People who lived at Clifton House were supported by staff who had been recruited using a formal process. We found that pre employment checks had been carried out to ensure suitable staff were employed.

Some of the care plans used by staff were not always up to date, some risk assessments and reviews had not been carried out. The standard of record keeping needed to be improved.