You are here

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 cared for in safe and accessible surroundings that support their health and welfare (outcome 10)

Enforcement action taken

We checked that people who use this service

  • Are in safe, accessible surroundings that promote their wellbeing.

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

The provider had not taken all the necessary steps to ensure that people who use the service, were protected against the risks of unsafe or unsuitable premises. There was inadequate maintenance and identification of environmental hazards.

Reasons for our judgement

The provider had not always taken steps to provide care in a home that was suitably designed and adequately maintained. During the inspection we were shown two upstairs bedrooms. In both of these bedrooms, the window could be opened in excess of safe limits and would have easily allowed a person to climb or fall through the opening. The service had 11 bedrooms on the upper floor and on the day of our visit, none of these were locked. We were aware from speaking with staff that there had been a recent incident at the home whereby a person had managed to leave the service, without staff knowing, from a ground floor window by breaking the chain restricting it from opening wider. We observed on the day of inspection and heard from other people who use the service that this person was able to access the upper floor and was at times entering the upstairs bedrooms. The failure to ensure that windows on the first floor were suitably restricted and that restrictors fitted to all windows were suitably maintained placed people at risk of harm.

During the inspection we found the water being discharged from bath taps hot to the touch. We used a thermometer to take the temperature of the hot water in two of the bathrooms we visited and found that in both cases this was at least 50 degrees centigrade. This is in excess of guidance in the Health and Safety Executive publication; Health and Safety in Care Homes. This states ‘If bathing facilities are accessible by vulnerable service users then the following set of steps should be taken; Fitting of thermostatic mixing valves (type 3) - to prevent water at greater than 44 °C being discharged from taps where there is potential for whole body immersion.

We brought this to the attention of the manager who agreed the water was very hot to touch. The manager told us that when staff assisted people to bathe they routinely tested the temperature of the bath water using a thermometer. When the manager showed us the downstairs bathroom, there was no thermometer present. We were told this downstairs bathroom was the most commonly used. The manager had not, prior to our visit, identified that the temperatures of the hot water being delivered to baths within the service were exceeding recommended temperatures. The bath taps also did not have thermostatic control valves fitted. This meant that the hot water from bath taps presented a risk of scalding to people using the service.

We found that the service had commissioned an external contractor to undertake an annual risk assessment for legionella. However, the manager was not undertaking regular monitoring and checks of the water system to ensure that temperatures remained within the parameters recommended to prevent the growth of legionella bacteria. We also found that there was no regular flushing of little used parts of their water system, for example the service had an unused shower which the manager could not confirm was being flushed in order to prevent the growth of legionella bacteria. This meant that people who used the service were not adequately protected from risks associated with the presence of legionella bacteria.