This inspection tool place on 8 and 9 August 2018. Our visit on 8 August was unannounced.

During the last inspection of The Clough in July 2017 we found a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because environmental risks had not always been identified and standards of infection control did not effectively prevent the spread of infection. 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 ‘is the service safe?’ and ‘is the service well led?’ to at least good. At this inspection we found improvements in these areas but we found further breaches of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014, relating to servicing records and poor medicines administration. You can see what action we told the provider to take at the back of the full version of the report.

The Clough Care home provides accommodation and personal care for up to 32 older people in a residential area of Bolton. At the time of our inspection there were 30 people living in the home.

Following the retirement of the previous registered manager the service had appointed a new manager who was in the process of applying to the Care Quality Commission (CQC) to become the registered manager. A registered manager is a person who has registered with the 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.

People told us they felt safe at The Clough, and the staff we spoke with demonstrated a good understanding of safeguarding and whistleblowing procedures. There were few incidents of alleged abuse but where these had been raised there was appropriate recording and follow up action taken.

There were enough staff on duty and staff were encouraged to spend time with the people who used the service. Staff were well trained and had access to refresher training to ensure that their knowledge was up to date and in line with current best practice. The service made appropriate checks during the recruitment process to ensure that new staff had the right attributes and character to work with vulnerable people. All new staff received a full induction and systems were in place to provide supervisions for staff. However not all staff had had a recent supervision although the manager was addressing this at the time of our inspection.

We saw risks were considered, including generic and environmental risks. Where identified, appropriate action was taken to minimise the risks. There was consideration of people’s needs prior to and immediately following people’s admission to The Clough and plans of care were regularly reviewed to ensure that changing needs were identified. Care records showed that the service worked in partnership with social workers and health care professionals and that people had access to healthcare services, including general practitioners (GPs), district nurses, and dieticians as necessary.

People told us that they enjoyed the food provided. The cooks understood the needs and preferences of people who used the service, and were aware of any specific dietary requirements. Where necessary, food and drink intake was monitored, and we saw hot and cold drinks were provided throughout the day.

The staff we spoke with demonstrated a good understanding of consent and choice. Where people lacked the capacity to consent to their care and treatment the appropriate authorisation to carry out their care had been sought and agreed by the relevant authority.

Staff communicated well with each other during their shifts, and any issues of concern were recorded and passed on at handover between shifts to ensure that needs were not overlooked and to allow consistent delivery of car

The Clough Care Home provides accommodation and personal care for up to 32 people, located in a quiet residential area in Bolton. On the day of our inspection there were 29 people living at the home.

The inspection took place on the 20 July and was unannounced.

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

At our last inspection in October 2014 we saw improvement was needed around people’s mealtime experience. At this inspection we found this experience had improved.

We saw some areas at the home which needed improvement from regular cleaning to reduce the risk of infection. The management team had completed environmental checks, however these had not identified the areas for improvement. We discussed this with the registered manager and they agreed the areas needed improvement. Staff infection control procedures were in the process of being updated to ensure people were not put at risk. The management team were looking at ways to improve the patio area to ensure people remained safe.

Staff we spoke with were aware of how to recognise signs of abuse, and systems were in place to guide them in reporting these. They were knowledgeable about how to manage people’s individual risks, and were able to respond to people’s needs. People told us they were supported in a safe way and had their medicines as prescribed.

People and their relatives told us staff knew how to meet their needs. Staff had up to date knowledge and training to support people. Staff respected people's rights to make their own decisions and choices about their support. People's permission was sought by staff before they helped support them. Staff gave people choices in a way they could understand by using appropriate communication methods. When people did not have the capacity to make their own specific decisions these were made in their best interests by people who knew them well and had been authorised to do this.

People had food and drink they enjoyed and had choices available to them, to maintain a healthy diet. People said they had access to health professionals when they needed to. Relatives were confident their family member was supported to maintain their well-being.

People said they were happy living at the home and were supported by patient and kind staff. Relatives told us they were happy with the care their family member received. They told us staff were caring and promoted people’s independence. People living at the home were able to see their friends and relatives as they wanted. We saw staff treated people with dignity and respect and had a good knowledge of people’s rights. They knew people well, and took people’s preferences into account and respected them.

People and their relatives were included in how care was provided. They knew how to raise complaints and felt confident that they would be listened to and action taken to resolve any concerns. The registered manager had a complaints process in place to ensure people were listened to and action could be taken if required.

The management team had identified people needed more interesting things to do. They had asked for ideas from people, families and staff and were in the process of making the improvements. People and their relatives were encouraged to attend regular meetings, to share their views about the quality of the service. The management team had actioned suggestions made by people, their families and staff where possible, and were making improvements.

The provider had systems in place to monitor the quality of care and treatment people living at the home received. These were not always effective at identifying improvements such a

We carried out this unannounced inspection under Section 60 of the Health and Social Care Act 2008 on 29 October 2014 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014. At the last inspection in October 2013 the home was found to be meeting all the regulatory requirements.

The Clough Care Home is a residential home accommodating up to 30 people in single rooms. Five rooms have en-suite facilities and there are four further bath and shower rooms. There are two lounges, a dining room and a conservatory and a new updated lift facility has recently been installed within the home.

There was a registered manager at the home. 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.

There were some aspects of the meal time we observed that would benefit from some improvement. These included the seating arrangements, timings of the sittings, cleanliness of the tables for the second sitting and communication with people who used the service around menus and choices available. We spoke with the manager about these concerns and they agreed to review the mealtime experience and make some changes, some with immediate effect.

The home was clean and tidy and people who used the service were well presented on the day of the inspection. We observed staff interacting with people who used the service and visitors with respect and people we spoke with told us the staff and management were approachable and concerns were dealt with in a timely way.

Activities and entertainment were offered to people who used the service on a regular basis. Those who did not wish to join in were free to follow their own interests and were supported to do this.

Care records were complete and up to date and included health and personal information and appropriate risk assessments. Staffing levels were adequate to meet the needs of the people who used the service. Staff files evidenced robust recruitment, thorough induction processes and regular supervision and appraisals.

Staff at the home had a good understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS), which help ensure people do not have their liberty unlawfully restricted. The manager was aware of how to apply for DoLS authorisation and was endeavouring to work within the local authority guidance with regard to making applications.

On our visit to The Clough we saw the home was clean and people who used the service were well presented. Staff spoke to people who used the service respectfully and were pleasant and friendly. Staff were aware of preserving dignity and privacy and could explain how they achieved this when administering care.

We looked at four care plans which contained relevant health and personal information. Most of the records were completed appropriately, although there were a small number of inconsistencies. Reviews were undertaken regularly and changes noted.

We spoke with four staff members who all demonstrated an awareness of safeguarding issues and were able to give examples of when they would report concerns. We discussed a recent safeguarding concern with the manager of the home. This had highlighted some issues including some procedures not being followed correctly and some poor recording. The manager agreed to put some actions into place immediately to address these issues.

The four staff members with whom we spoke felt they were well supported by team members, senior staff and the provider. Staff meetings were held regularly, training was on-going and communication was constant between staff and management.

Satisfaction questionnaires were sent out regularly and there was constant dialogue between staff and people who used the service to ensure their views were sought. Audits were carried out and issues raised by these were addressed in a timely way.

We visited The Clough on 3 January 2013 and found the home to be warm, clean and bright. People who used the service were well presented and we witnessed staff interacting with them in a friendly, polite manner and respecting their dignity and privacy.

We looked at six care plans and saw that they contained relevant medical and health information, personal preferences and social history, evidence of partnership working, risk assessments and monitoring charts. We saw that the care plans were regularly reviewed and updated.

We spoke with four people who used the service, one told us “I feel safe, I’ve nothing to worry about.” Another person told us “we are very well looked after.” We spoke with three visitors and one said “staff are very friendly and approachable” whilst another told us “staff all go out of their way to help.”

We saw there were relevant policies and procedures around safeguarding and spoke with three members of staff who demonstrated an understanding of the issues. The staff with whom we spoke were confident to report any issues they may encounter.

We saw that recruitment and induction procedures were robust and staff employed had relevant qualifications and skills and training was ongoing.

We saw that the home had procedures in place to quality assure the service, including customer satisfaction questionnaires and regular residents’ meetings. Any issues raised or complaints were taken seriously and followed up appropriately.

During our visit we spoke with four people. We were told "It's a lovely atmosphere. I think we're all happy here" and "We always have someone there for us". People said they could choose how they spent their day and that they could get up and go to bed when they pleased. We heard that activities were regularly arranged, and if people were able to staff would take them out on trips, for example to local shopping centres.

One person said "I wouldn't change anything whatsoever" and we were told that if anyone had a problem they were confident the head of care would take it seriously.