Radcliffe Manor House

People's experience of using this service and what we found.

We undertook this targeted inspection to check whether the Warning Notice we previously served in relation to Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Radcliffe Manor house on our website at www.cqc.org.uk.

Rating at last inspection and update

The last rating for this service was Requires Improvement (published on 23 May 2023)

Why we inspected

We undertook this targeted inspection to check on a specific concern we had about personal safety. The overall rating for the service has not changed following this targeted inspection and remains Requires improvement.

We use targeted inspections to follow up on Warning Notices or to check concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

Follow up

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

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

Risks were not always assessed, monitored and mitigated for all the people living in the home.

Medicines were not always managed in a safe way. Medicine audits failed to identify some issues and concerns.

The home was clean, and infections were managed well, however there were some concerns regarding how the building was maintained.

Staff were recruited safely and in line with the providers policy and procedures, however some people and staff felt more staff would help cover busy times.

People were protected from avoidable harm and staff knew how to raise concerns about poor practice. Referrals were submitted to the local authority safeguarding teams and notified to CQC.

The providers audits did not always ensure health and safety guidelines were followed.

We have made a recommendation about the provider following current health and safety guidelines for testing water temperatures and managing Legionella.

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.

Management and staff were aware of their roles and responsibilities. The provider adhered to their legal obligations.

The provider took action to drive improvement for care planning and recording care needs to ensure staff provided care and support in an efficient way.

The service worked well with healthcare professionals to ensure people’s care needs were met.

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

The last rating for this service was good (published 19 January 2019).

Why we inspected

We received concerns in relation to an inquest response from the coroner’s office. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of Safe and well-led only.

We looked at infection prevention and control 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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Radcliffe Manor House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have made 1 recommendation in regard to maintaining safety.

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

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

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

We found the following examples of good practice.

There was a restriction on visiting the service at the time of the inspection. There were procedures in place for visitors to the service, including healthcare professionals and relatives to reduce and prevent the spread of infection.

The provider ensured people maintained contact with relatives by staff supporting them with skype, face time and telephone calls. The deputy manager told us they had accommodated garden visits and had reviewed current guidance for accepting visitors.

There was a clear regular programme for staff and people living in the home to be tested for COVID-19. This meant swift action could be taken if or when positive tests were received. The provider had robust monitoring systems in place for when people required a retest.

Staff followed procedures for don and doffing PPE and how to dispose of it safely, in line with government guidelines. All staff wore appropriate PPE, which was in good supply. Posters and information about COVID-19 were visable throughout the service. The provider was also working with Public Health England and local infection control teams to ensure they had appropriate safety measures in place.

A robust contingency plan was in place and used, for when positive testing or isolation for staff or people arose. Agency staff were used to cover shortfalls in staffing, due to staff testing positive for COVID-19.

Handover meetings were completed in line with safe distancing guidelines.

People using the service who had tested positive had isolated in their own rooms when appropriate. Arrangements were in place to reduce the spread of infection. Peoples individual needs were considered to ensure everyone was kept safe.

The home was very clean and tidy. Housekeeping staff told us they had increased the cleaning regime. Cleaning schedules were under review to incorporate new ways of working, for example all touch point cleaning. Staff confirmed they had recorded when touch points or increased cleaning had been completed and that they were awaiting a new form.

Deep cleaning had taken place in all communal areas and the housekeeping staff told us they were in the process of deep cleaning all people’s bedrooms as they came out of isolation.

Further information is in the detailed findings below.

At our last inspection we rated the service as overall ‘Good’. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. There were 26 people using the service at the time of our visit. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

People were kept safe at the service. Staff recognised signs of any abuse and knew the process to follow to report such incidents. Staffing levels were maintained to ensure people were fully supported in a safe manner. Medicines were stored and handled in line with current regulations.

People’s consent was obtained before any support or care was provided. Staff completed regular training and refresher courses to ensure their knowledge was up to date and people’s needs were met in the correct way. People had access to health care professionals and had a choice of food throughout the day.

Staff were caring and understood the needs of the people receiving support and how their choses were to be provided. People’s independence was respected and supported, with people enjoying trips outside the service when they wanted.

There was a range of activities offered and regular discussions about how people wanted to spend their days. The local community was regularly accessed and a range of meals were available each day with snacks offered between mealtimes. Contact with family and friends was supported and encouraged.

People were happy with the leadership of the service and told us that they knew the registered manager who was actively involved in the daily routines. Staff felt they were fully supported by the management team and were included in any developments of the service.

On the day of our inspection there was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staff could identify the potential signs of abuse and knew who to report any concerns to. Risks to people’s safety were continually assessed and reviewed. A risk of an unlocked door to the home was identified, but the registered manager had the processes in place to manage that risk whilst not restricting people’s freedom. There were enough staff to keep people safe and people’s medicines were managed safely.

People were supported by staff who completed an induction prior to commencing their role and had the skills, training in place and their performance regularly reviewed to enable them to support people effectively.

The principles of the Mental Capacity Act (2005), including Deprivation of Liberty Safeguards, had been followed when decisions were made about people’s care. People spoke highly of the food provided and were supported to follow a healthy and balanced diet. People’s day to day health needs were met by staff. A visiting healthcare professional spoke highly of the way staff supported people. Referrals to relevant health services were made where needed.

Staff were kind, caring and compassionate. Staff understood people’s needs and listened to and acted upon their views. People’s privacy and dignity were maintained and staff spoke with them in a respectful way. People were involved with decisions made about their care and were encouraged to lead as independent a life as possible. People were provided with information about how they could access independent advocates. People’s friends and relatives were able to visit whenever they wanted to.

The majority of people spoke positively about the activities provided at the home. People’s care records were person centred and focused on providing them with care and support in the way in which they wanted. People were provided with the information they needed if they wished to make a complaint.

The registered manager led the service well and was respected and well liked. People were encouraged to maintain links with their local community. Staff understood what was expected of them in their role. People were encouraged to provide feedback about the quality of the service and this information was used to make improvements. Quality assurance processes were in place to ensure people and others were safe in the home.

We spoke with three people using the service. They told us they were happy with the arrangements for their medication and they always got it on time.

We observed a staff member administering medication to people in the dining room at lunchtime. We saw they wore a tabard to identify their role and they were not disturbed by other staff members. We saw they waited with people whilst they took their medication. This meant people who used the service were supported by staff when they took their medicines.

We found that medicines were safely administered and appropriate arrangements were in place in relation to the recording of medicine.

We spoke with three relatives. They told us their family members received good care that met their needs. One relative said, 'I think it's very good actually.'

During our visit we saw positive interactions between staff and people using the service. We spent 40 minutes observing the care at lunchtime in the dining room. We saw staff provided support to people who needed this. We also saw staff communicated warmly with people as they were supporting them.

People using the service who we spoke with told us they were happy with arrangements for their medication. However, we found some gaps in the medication records. We also found that medication was not always stored at an appropriate temperature.

We found that there were enough qualified, skilled and experienced staff to meet people's needs.

We also found staff received inductions, supervision, training and appraisals.

We found that the provider had an effective system to regularly assess and monitor the quality of service that people receive.

We spoke with three people using the service. One person said the care was, 'Smashing'. Another person said, 'They look after you very well.' The third person told us they received the care they needed and said it was 'reasonable'.

We found that the provider had begun to make some improvements. The deputy manager told us they were producing new care records using new care documentation. However, we saw mixed evidence in one care record as to how the person's needs had been assessed and reviewed.

We found that the provider had taken some action to address training gaps, but we still found some gaps. We found no evidence of an induction in one staff file and saw that induction documentation had not been fully completed in two other files. We saw no evidence of recent staff supervision or appraisals in three staff files we looked at.

We did not inspect how medicines were managed during our previous visit. However, recent information we received led us to report on this outcome. We found gaps on the medication administration records (MAR) charts.