Mona Cliffe Care Home

Updated 20 May 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector.

Service and service type

Mona Cliffe Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Mona Cliffe Care Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced. Inspection activity started on 13 April 2022 and ended on 21 April 2022. We visited the location’s service on 13 April 2022.

What we did before the inspection

We reviewed information we had received about the service since the last inspection and we sought feedback from the local authority. We used the information the provider sent us in the provider information return. This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with two people who used the service and one relative about their experience of the care provided. We spoke with four members of staff including the registered manager and care workers. We also spoke to a healthcare professional , who was visiting the service at the time of inspection. We reviewed a range of records. This included two people's care records and various medication records. We looked at two staff files in relation to recruitment. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 20 May 2022

About the service

Mona Cliffe Care Home is a care home providing personal care for up to 23 people. The service provides support to older people. At the time of our inspection there were 13 people using the service. The care home accommodates people across two floors in one building.

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

People were safeguarded from abuse, appropriate risk assessments were in place and people told us they felt safe. The home was clean and tidy but did require some modernisation. Some records relating to infection prevention and control (IPC) required updating which was done during our inspection. Moving and handling training had been completed by staff and their competency had been assessed. Adequate staffing levels were in place, but recruitment procedures needed improving. We made a recommendation the service reviews their recruitment process. Some records relating to medicines required updating. The home was working in line with current guidance regarding visiting in care homes.

The registered manager had worked hard to improve the governance processes, however, there was a need for consistent provider monitoring following the COVID restrictions. We made a recommendation the provider ensures appropriate oversight of the service. Improvements were needed in relation to the General Data Protection Regulations (GDPR) policy. We made a recommendation that the provider ensures they are working inline with current GDPR guidance. Staff, people and relatives were kept up to date with any necessary information, however the home had limited examples of lessons learned and had not conducted any surveys for staff or people that use the service. We made a recommendation that the provider seeks regular feedback from staff and people. Staff told us they enjoyed their roles and both staff and people spoke positively about the registered manager.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 10 September 2019). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

At our last inspection we made recommendations regarding moving and handling, best interest decisions and obtaining staff feedback. At this inspection we found the provider had acted on two of these recommendations, however there was a continued recommendation around obtaining staff feedback.

Why we inspected

This inspection was prompted by a review of the information we held about this service. We looked at IPC measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We carried out an unannounced comprehensive inspection of this service between 8 May 2019 and 24 June 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve good governance and safe care and treatment.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions safe and well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Mona Cliffe Care Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.