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Clifford House Residential Care Home Good

All reports

Inspection report

Date of Inspection: 27 November 2013
Date of Publication: 4 January 2014
Inspection Report published 04 January 2014 PDF

People should be protected from abuse and staff should respect their human rights (outcome 7)

Not met this standard

We checked that people who use this service

  • Are protected from abuse, or the risk of abuse, and their human rights are respected and upheld.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 27 November 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with staff and reviewed information given to us by the provider.

Our judgement

People were not protected from the risk of abuse, because the provider had not taken reasonable steps to ensure staff could identify potential abuse through up to date training and knowledge of safeguarding policies and procedures. Safeguarding incidents were not always identified and reported appropriately. Adequate arrangements were not in place for ensuring that the service applied for Deprivation of Liberty Safeguards where people may have been experiencing restrictions on their liberty.

Reasons for our judgement

People who lived in the home said they felt safe living at Clifford House. Those we spoke with were confident they could share concerns with any staff member or the manager and that they would act upon these. For example, one person told us the manager had responded promptly when she had highlighted concerns about her security when in her room by enabling her to have a lock on her bedroom door. She told us that this had made her feel more secure.

Staff we spoke with demonstrated a commitment to protecting people from abuse and were clear about whom they would report any concerns about abuse to. They also felt that any concerns they might raise would be taken seriously and responded to appropriately. However we found some staff had not completed or recently updated their safeguarding training. Staff we spoke to only demonstrated a basic knowledge of the types of abuse and how these might be displayed within the context of the service. None of the staff we spoke with were aware of whether the service had a whistleblowing policy or what the term meant. The lack of suitable arrangements for making sure staff received, updated and understood training in relation to safeguarding and whistleblowing meant they might not recognise signs of abuse or feel confident to report concerns without fearing that they might be treated unfairly as a result.

During the inspection we were informed that there had been a recent incident where a vulnerable person had managed to leave the home through a ground floor window at night, without staff knowing. The person had been returned to the service by the police. This incident had not been raised as a safeguarding alert with the local authority safeguarding team by the service. The manager told us he did not know he had a responsibility to notify the local safeguarding team when a service user went missing. His failure to do this meant the safeguarding team was unable to assess in a timely manner whether the home had taken appropriate action in relation to the incident that had occurred and this could have placed the service user at risk of receiving inappropriate care.

On the day of our inspection, we found evidence that a person living at the service who lacked capacity to make decisions around their care and treatment may have been experiencing restrictions of their liberty in order to protect them from harm. For example, staff were dissuading this person from leaving the care home despite this being his wish. In the event of such restrictions being necessary for the protection of the person, it is the responsibility of the care home (managing authority) to apply for an authorisation of the restrictions in line with the MCA (2005) Deprivation of Liberty Safeguards (DOLS). We spoke with the manager who told us that this had not been done. This was despite the fact that the person had been subject to a DOLS order in their previous care setting. When we spoke with the manager about this, it appeared that he did not have a full understanding of his responsibilities as the managing authority under the DOLS. This meant there was a risk that people were not subject to the safeguards introduced in law to ensure that the care and treatment they received was in their best interests and any restrictions were lawful and not excessive.