About the service:

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.

This inspection took place on 11 December 2017 and was unannounced. A second day of inspection took place on 14 December 2017 and was announced.

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.

This inspection took place on 31 October and 7 November 2016 and was unannounced. We last inspected the home on 22, 25 and 29 February 2016 and found the provider had breached the regulations for person-centred care, good governance, recruitment and staffing. Following the inspection we issued warning notices to the provider. The home was placed in special measures due to the home’s overall rating being inadequate.

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

This inspection took place on 22, 25 and 29 February 2016 and was unannounced. We last inspected the home on 22 September 2015 and found the registered provider had breached the regulations for managing medicines. Following the inspection we issued a warning notice to the registered provider.

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 wa

We carried out an unannounced comprehensive inspection of this service on 12 and 19 January 2015. A breach of legal requirements was found because medicines were not being managed in the right way and staff did not follow the requirements of the Mental Capacity Act 2005 (MCA) where people lacked capacity to consent to their care. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to these breaches of the regulations.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met the legal requirements. This report only covers our findings in relation to those requirements. 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.

We found the assurances the provider had given in the action plan had not been met with regard to the management of medicines. This meant the registered provider had continued to breach the regulations with regard to medicines management. Medicines were not always managed safely for people and records had not been completed correctly. People did not receive their medicines at the times they needed them and in a safe way. Medicines were not obtained, administered and recorded properly.

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

We found the assurances the provider had given in the action plan had been met with regard to the requirements of the MCA. People had been assessed under the MCA and where required the local authority had granted Deprivation of Liberty Safeguards (DoLS) authorisations. Specific MCA training had been provided to raise staff awareness and help them provide the support people who lack capacity need with making decisions.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Mrs Andrena Piggins' name appears because she was still a Registered Manager on our register at the time of our inspection.

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.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

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".

We carried out this inspection because concerns had been raised to us about the standard of nutrition and hydration within the service. During this inspection we spoke with people who used the service and the cook.

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.

People who lived at Clifton House were able to express their preferences and were supported in a way that maintained their dignity and independence. Activities were organised and people were happy with the care they received.

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.

During the inspection we spoke with people and their relatives about life at Clifton House. They were happy with the care and service they and their relatives received.

A relative said "My mother is happy here and that helps me sleep at night" and "The staff are lovely here." One person said "Staff are lovely and very helpful." Another person said "I have friends here and we have a right good chat."

This inspection took place over two days. The visit on 12 January 2015 was unannounced and the visit on 19 January was announced. Following our last inspection of Clifton House Residential Care Home we told the provider they had breached the regulations relating to the management of medicines. During this inspection we found the provider had met the assurances they gave in their action plan and had developed systems to check on the quality of medicines records.

We found the provider had breached Regulations 13 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. Although we found the quality of recording on people’s medicines administration records had improved, improvements were needed to the management of medicines. Medicines were not always managed safely for people. Records had not been completed correctly as for some medicines no record had been made of medicines received mid-month, or carried forward from the previous month. We have made a recommendation about the management of medicines. The provider was also not meeting the requirements of the Mental Capacity Act 2005 including the Deprivation of liberty safeguards.

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

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 13 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.

People and family members told us the home was safe. People commented, “Very safe”, and, “Very safe, no problems in that department.” One family member told us they thought the home was a “friendly and safe environment.” People, family members and staff said they felt there was enough staff to meet their needs. One person said, “Always seems to be plenty of staff.” The provider followed its recruitment procedure to check new staff were suitable to care for and support vulnerable adults.

People told us they were asked for their permission before receiving any care and that staff respected their decision. One person said, “I am not made to do anything if I don’t want to.” Another person said, “I don’t have to join in.” Another person said, “You can do what you like.”

People told us they received good care at the home and were treated with dignity and respect. Their comments included, “Very good care”, “Staff look after me very well”, “The care is pretty good”, “Nice staff; they are excellent”, “All staff are very good, they do everything in their power to help”, and, “Staff are always polite.”

Family members also confirmed their relatives received good care. One family member said, “Very good home.” They also said staff were “very good with [my relative]. Another family member said, “The home is brilliant, no faults at all.”

Staff had a good understanding of safeguarding and whistle blowing policies and procedures. They knew how to report concerns. All of the staff we spoke with said they did not have any concerns about the care provided, or the safety of the people living in the home. They told us they felt able to raise concerns and felt the manager would deal with their concerns straightaway. One staff member said, “Always, residents are put first.”

The provider undertook standard assessments to help protect people from a range of potential risks, such as poor nutrition, skin damage and falling.

People and family members were happy with the home’s environment. One person described the home as “clean, neat and tidy.” Another person said, “[The] rooms are always neat and tidy.” Family members described the home as “old style” and “home from home.” We observed during our inspection the home was clean, with no unpleasant odours and was well maintained. We saw the provider undertook regular health and safety check of the premises to check they were safe. The provider had emergency procedures in place, including personal emergency evacuation plans (PEEPS) for people who used the service. We found that not all of the recommendations from the most recent fire risk assessment had been completed. We recommended these areas are considered as a priority.

The provider was not acting in according with the Mental Capacity Act 2005 (MCA), as we saw no evidence people had been assessed in line with the new scope of Deprivation of Liberty Safeguards (DoLS), or contact with the local safeguarding authority had been made for further advice. Staff had not completed training on MCA, including DoLS.

Staff told us they felt well supported and had regular supervision with the manager. One staff member commented they felt “really supported.” They also told us the provider was supportive of staff doing training and confirmed their training was up to date. One staff member told us, “We are always doing training.”

People gave us positive feedback about the meals they were given. One person commented, “The food is not bad. You can have what you like. They [staff] will suggest things. You can have what you want.” We observed people received the support they needed to meet their nutritional needs. However, during our lunch-time observation, we saw some people’s needs were not always considered ahead of completing tasks.

People said staff supported them to meet their health care needs. One person said, “If I need to see a doctor, [staff] will send for the doctor”, and, “I have medical checks.” Another person said staff were “Quick to call for the doctor.” One family member said, “Every time there is a problem the doctor is brought in or [my relative] is taken to hospital.” Another family member said staff were “very hot on getting the doctor out” when people were unwell.

Information about how to access independent advice and support (advocacy) was displayed in a locked display cabinet near the entrance to the home. However, we were unable to establish how up to date this information was.

People had up to date care plans which were individualised and took account of their choices, likes and dislikes. We saw where people had particular health problems; short term care plans had been developed. Records showed that care plans were reviewed regularly. Some people told us they seen their care plan and had been involved in deciding what was in it.

People and family members knew who to go to if they had any concerns. One person said they would speak with the registered manager. One family member said, “I would go to the manager if I needed to.” The registered manager told us there had been no formal complaints received in the past 12 months.

People and family members had opportunities to give their views about the home, including meetings with the manager, a suggestion box and questionnaires. Family members we spoke with told us they were aware of the manager’s meetings with residents and relatives. The information displayed on the home’s notice board showing the dates of future meetings had not been updated.

The home had a registered manager. People and family members told us the registered manager was approachable. One person said, “The manager is very good, very caring. She is very conscientious.” Another person said, “The manager is very nice, very approachable and very easy to get on with.” They also said all of the staff were approachable. One family member said, “The manager is absolutely brilliant, such a nice person, friendly but professional.”

People and family members said they felt the home had a good atmosphere. One person said, “Everybody gets on.” One staff member described the atmosphere as “lovely.” Another staff member said, “[The atmosphere] feels really nice, lovely.”

There was a system of checks and audits in place to assess the quality and safety of the care people received. This consisted of monthly audits of people’s weight, minor concerns received, accidents and care plans. We found these audits were used to check that appropriate action had been taken to respond to any issues identified or changes in people’s needs.