Archived: Radcliffe Gardens Nursing Home

Updated 21 February 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check 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.

This inspection took place on 11 January 2017 and was unannounced. The inspection team consisted of one adult social care inspector and an expert-by-experience with a background in care for older people. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service.

At the time of our inspection there were 19 people living in the home. During our visit we spoke with the registered manager and a further five members of staff. We also spoke with 10 people and seven visitors as well as two health professionals. We spent some time looking at the documents and records that related to people’s care and the management of the service. We looked at three people’s care plans.

Before the inspection the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

Before our inspection, we reviewed all the information we held about the home. We contacted the local authority and Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

Updated 21 February 2017

This was an unannounced inspection carried out on 11 January 2017. Our last inspection took place on 13 October 2015 when we gave an overall rating of the service as ‘Requires Improvement’. We found two breaches of the legal requirements in relation to the recruitment of staff and people were not protected from being deprived of their liberty. At this inspection we saw improvements had been made.

Radcliffe Gardens Nursing Home is registered to provide accommodation for up to 20 people who require nursing or personal care. The home is located in a quiet area of Pudsey and close to local amenities, shops and churches. The home is on two levels with lift access and has a garden area and car parking to the front of the building.

At the time of our inspection there was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Medicines were not always stored safely as a new delivery of medicines was found in an accessible area of the home along with confidential information. Protocols for the use of ‘as and when’ required medicines needed more detail. Controlled drugs were managed appropriately.

Windows were not restricted as required by the Health and Safety Executive. The registered provider took appropriate action to remedy this following our inspection. Other maintenance and fire safety checks had been carried out.

Mental capacity assessments (MCA) had been completed, although these were not decision specific. Best interest’s decisions had not been completed appropriately as relevant individuals had not been consulted. We recommended the registered manager look at guidance on the appropriate use of best interest decisions. Applications for Deprivation of Liberty Safeguards had been appropriately made to the local authority.

There were sufficient numbers of staff on duty. Staff received support through their induction, supervision and appraisal. Records showed staff were mostly up-to-date with their training needs. Recruitment was appropriately managed as relevant background checks had been carried out and professional checks were taking place. Risks to people had been appropriately managed.

People who lived at Radcliffe Gardens Nursing Home felt safe. Two safeguarding incidents had not been referred to the Care Quality Commission. We discussed this with the registered manager. Staff knew how to recognise and report abuse.

People received access to healthcare services when they needed this and health professional spoke very positively about this service. Special dietary requirements were well managed and people received enough to eat and drink.

Care plans were sufficient to meet people’s care needs. Some gaps around a risk assessment and guidance for staff to respond to challenging behaviour were discussed with the registered manager. People and relatives were involved in care planning.

People received care from a staff team who were very familiar with their preferences. People’s privacy and dignity was respected at all times. Staff spoke with people nicely and were kind and attentive when people needed assistance.

The registered provider had not identified the areas of concern we found during this inspection. A number of quality audits were carried out and the registered provider visited the service to carry out their own checks. Surveys and meetings gave people and relatives an opportunity to feedback about the quality of the service. People knew how to complain and when this happened responses were provided within identified timescales.

People, relatives and staff were complimentary about the registered manager who had a visible presence in the home and was approachable. The staff team worked well together.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014. You can see the action we have told the provider to take at the end of this report.