Radcliffe Manor House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question inadequate. At this assessment the rating has changed to good.

The provider was previously in breach of the legal regulation in relation to safe care and treatment. At this assessment, we found improvements had been made and the provider was no longer in breach of this regulation.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify good practice. The provider continues to embed this into the service.

Accidents and incidents were recorded and reviewed so any trends or patterns could be identified and ways of working could be introduced to reduce the likelihood of recurrence. The provider told us they are working to further embed lessons learnt, by sharing them more widely and frequently within the home.

Staff told us they felt able to raise concerns with management and were listened to. Staff told us that changes were communicated more effectively, usually in handovers. This meant that staff felt more confident in supporting people who live at the service.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care.

Hospital passports and grab sheets contained important information. Where we found missing information, such as some health conditions. This meant that people were at risk of receiving care not in line with their needs if they were to attend hospital. This was raised with the manager at the time if the assessment who told us that they would rectify this.

The manager worked with others in order to make improvements within the service. They maintained regular contact with the local authority, social workers, GPs and district nurses where required. Staff knew when to report concerns to management and who would escalate the concerns to external professionals where needed. This meant that all involved in people’s care would have clear guidance on how the person liked to be supported.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

We saw evidence of where safeguarding concerns had been raised with the safeguarding team and contained responses to enable actions and lessons learnt to be implemented. Staff had completed safeguarding training, and they understood their responsibility to report any concerns to the management.

People who lived at Radcliffe Manor House and their families told us that they felt safe. One relative told us, “It’s honestly the best one for [family member] and I could never fault the care. They ring me when anything goes wrong. I’ve no safety concerns.”

We found some Mental Capacity Act (2005) (MCA) assessments were in place, however they were not always completed or lacked the key principles of The Act to make best interests decisions. Mental capacity should be reviewed regularly in line with the Mental Capacity Act (MCA)(2005), reassessing, and implementing best interests decisions and a Deprivation of Liberty Safeguards (DoLS) application if applicable. We found MCA assessments had not been reviewed regularly in all necessary areas; however, staff told us they knew people and their wishes well. Relatives also told us that staff knew their loved ones well and contacted them regarding wishes and changes to their care. We did see evidence of DoLS being submitted appropriately which meant that restrictions placed upon people were lawful. DoLS are legal safeguards under the Mental Capacity Act 2005 designed to protect people who lack the mental capacity to consent to their care or treatment, and who are being deprived of their liberty in a hospital or care home.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff told us they encouraged people to make their own choices, and they respected their decisions.

We found that staff did not have clear written guidance in place to ensure people were supported in a safe way and according to their needs, however we saw that staff knew people’s needs well and managed risk effectively. Although staff knew people well, lack of up to date care planning meant people were at risk of receiving care that was against their wishes or recommendations. The provider prioritised updating the care plans following feedback and provided evidence of care plans that were reflective of people's needs.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Concerns raised regarding the environment at the last assessment had been addressed by the provider including altering banister heights and fixing wardrobed to walls. This meant that people were not at risk of wardrobes falling on them should they open them.

The provider had their own improvement plan for the building and told us they will, “continue with the refurbishment programme of bedrooms and complete the replacement of the assisted bath, so that residents can enjoy the facilities”. The provider had ordered a new bath and told us this would be installed shortly. People still had access to bathing facilities whilst these changes took place.

Throughout the day, we observed staff assisting people with different equipment. All instances we saw were carried out in a safe and appropriate manner.

People told us they were provided with appropriate equipment to meet their needs. There is also the option for an acoustic monitoring system in people’s bedrooms. One relative told us, “[The provider] got a new type of bed for [relative’s] room so [they’d] be safer. [They] wanders but the past movement system didn’t work properly. The new system installed alerts movements and sounds too, like if [they are] coughing or calling out. [They’ve] had no falls since that’s been put in place.”

The home was safe in the event of a fire. Corridors were clear of any blockages, allowing people to follow easy to read escape routes. Staff had access to fire-fighting equipment.
Windows were unable to be opened wide. This safety feature prevents people from falling or climbing out and is in line with guidance from the Health and Safety Executive.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staffing levels were reflective to meet the needs of the people living at Radcliffe Manor House and were reviewed regularly to ensure that adequate staffing was in place. Staff told us that since there had been an increase in staffing levels, they were able to give more time when supporting people. We observed call bells were responded to in a timely manner which meant that people were not left waiting when support was required. Some people told us it “can feel like they are waiting a while”, with one person telling us, “It can vary, and it can feel like a long time when they’re busy”. On reviewing the call bell audits, call bell response times were in line with the call bell policy which meant people received care and support as they needed it.

We did not look at infection prevention and control during this assessment. The score for this quality statement is based on the previous rating.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

We observed staff explain to people what medicines were administered, and also people were asked if they needed their prescribed ‘as needed’ medicines such as pain relief and given a choice as to whether they had this or not.

Topical creams were stored in safes in people’s bedrooms; however, we did find some of these safes to be unlocked. This increased the risk of harm to people if used or ingested. This was raised with the provider who assured us they would raise this with staff to ensure that they were locking the safes after using the topical creams.

People told us they were supported with their medicines. One person told us, “They stay and help me to take mine one by one.” A relative also told us “They don’t rush [relative] and tell them what their tablets are for as they are aware of their medication. [Relative] gets them [medicines] on time.”