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Clifton Court Nursing Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 10 December 2019

Clifton Court Nursing Home is a care home providing accommodation with personal and nursing care for up to 40 people. Some admissions to the home are part of the ‘Discharge to assess’ (D2A) scheme (funded by the Clinical Commissioning Groups). The D2A scheme aims to ensure people are moved out of hospital (when medically stable) to receive a period of rehabilitation/reablement in a residential setting, prior to assessment of their long-term care needs. At the time of our inspection visit there were 34 people living at the home, three of whom were on the D2A scheme.

People’s experience of using this service and what we found

At our last inspection in June 2018, we rated the service as good. At this inspection we found the registered manager and provider needed to improve risk management procedures, and demonstrate they were consistently monitoring and mitigating risks to people’s safety. Oversight of staffing levels also required improvement.

Systems designed to check on and improve the quality of the service provided were not always effective, as they had not picked up some of the issues we identified.

The service was led by a provider, a part time registered manager and management team which included a part time deputy manager, a nursing team and a care manager. People and staff gave us mixed feedback about whether the management team were approachable and responsive to their concerns and feedback.

We received mixed feedback from people, relatives and staff about whether there were enough staff to keep people safe and respond to their preferences and health needs. Following our feedback, the provider acted straight away to increase care staff on each shift. They also planned to increase management support.

People were not always supported to have choice and control of their care decisions. Improvements were required in how people's consent to their care and treatment was sought and recorded.

People's nutritional needs were being met. However, some records of how staff supported people to eat and drink enough to maintain their health required improvement.

People received kind and compassionate care from care and nursing. The staff team worked hard to promote people’s dignity and prevent people from becoming unwell. Staff understood how to keep people safe from the risk of abuse, and embraced team working to reduce potential risks to people.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last focussed inspection report for Clifton Court was published in June 2018 and we gave an overall rating of good. At this inspection we found the service had not sustained this rating and have rated the service as requires improvement in all areas.

Why we inspected

This was a responsive comprehensive inspection prompted in part due to concerns received about staffing levels and the leadership of the home. A decision was made for us to inspect and examine those risks. The inspection was also prompted in part by a notification of a specific incident, following which a person using the service died. This incident is subject to a criminal investigation. As a result, this inspection did not examine the circumstances of the incident. The information CQC received about the incident indicated concerns around safety of people at the home. This inspection examined those risks.


We have identified two breaches in relation to safe care and treatment of people and good governance at this inspection.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas


Requires improvement

Updated 10 December 2019

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 10 December 2019

The service was not always effective.

Details are in our effective findings below.


Requires improvement

Updated 10 December 2019

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 10 December 2019

The service was not always responsive.

Details are in our responsive findings below.


Requires improvement

Updated 10 December 2019

The service was not always well led.

Details are in our well led findings below.