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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

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Not met this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

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

Measures in place for monitoring the quality and safety of the premises had not been effective in identifying risks. There were not adequate measures in place for regularly assessing and monitoring the quality of the service.

Reasons for our judgement

People who use the service, their representatives and visiting professionals were asked for their views about the quality of the service. We saw that the manager had undertaken a customer satisfaction survey in November 2012. Responses from people using the service were generally positive and included feedback that they felt they were treated with dignity and respect and had confidence in the staff who responded promptly to their needs. There was evidence the manager had reviewed the responses from the survey and used the findings to reach judgements about how the service could be improved. However 30% of relatives and 54% of people who used the service, felt improvements were needed in the provision of social activities and entertainment. The manager told us he had tried to arrange additional outings but the take up had been poor and so this was an on-going challenge for the service. The manager told us he was due to undertake another satisfaction survey shortly.

We found evidence the manager was informally seeking the views of staff working within the service. The manager told us he held staff meetings two or three times a year. We saw minutes of the most recent meeting held in October 2013. This was well attended and showed evidence of opportunities for staff to raise concerns and discuss practice issues.

The service had commissioned external audits to help assist them in identifying issues that might affect the safety of the premises and people using the service. For example, the service had undertaken a fire risk assessment in 2013. In June 2013, the service had undertaken Portable Appliance Testing (PAT) and this resulted in two appliances being destroyed as they were not safe. The service had also had a legionella risk assessment undertaken in November 2013, but the results of this were not available on the day of the inspection. The service commissioned an annual fire risk report. We saw that the recommendations from the most recent report had been completed. This included the drafting of a Personal Emergency Evacuation Plan (PEEP) for each person using the service.

We saw that a health and safety environmental report had been produced following a site visit in March 2013. However, we noted that this report had not identified issues in relation to the upstairs windows opening too wide or the hot water temperatures exceeding recommended levels. This meant that whilst the service had arrangements in place to identify, assess and manage risks associated with the environment, these were not always effective or did not provide them with the information they needed to ensure the safety and welfare of service users.

It was also not always clear the provider was learning from incidents and accidents and that action had been taken to mitigate any further risk. For example, we were aware that a person had left the home without staff knowing through his bedroom window. Our review of this incident found that the manager had not carried out a suitable risk assessment to ensure this person, and others who might also be at risk, were not able to do the same. This meant that the service had not taken adequate steps to identify, assess and manage risks relating to the health, welfare and safety of people using the service.

We found that the manager did not have a robust system in place for regularly assessing and monitoring the quality or risks relating to the care provided. For example, we found the manager had not undertaken formal audits of people’s care plans to ensure these provided staff with accurate and detailed information about how to meet their needs. In addition, the manager told us that medication audits were not completed on a regular basis. We also found that whilst the provider had taken some steps to identify what training staff required, the manager did not have appropriate measures in place to regularly assess and identify where staff training was not in line with the service’s training stated sched