Clifton Manor Nursing Home

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 good. At this assessment the rating has changed to outstanding.

This meant people were protected by a strong and distinctive approach to safeguarding, including positive risk-taking to maximise their control over their lives. People were fully involved, and the provider was open and transparent when things went wrong.

This service scored 88 (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 strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

The registered manager demonstrated a clear understanding of their duty of candour responsibilities. Records showed people and their relatives were kept informed when incidents occurred through open discussions and written correspondence. Clear processes were in place to ensure people were involved, supported and kept updated throughout.

Incidents were thoroughly reviewed to understand both immediate causes and any wider themes or patterns. The management team analysed information from incidents, accidents and other events to identify opportunities to improve care and reduce future risks. The provider could clearly demonstrate how learning from these reviews informed service improvement priorities and improvements across the service resulting in better outcomes for people.

For example, falls were reviewed in detail, considering individual circumstances alongside environmental, equipment and clinical factors. Analysis identified recurring themes, including risks associated with wheelchair positioning, periods following significant medication changes and specific points during daily routines when people required additional support. The provider used this learning to make improvements to care delivery, equipment checks, staff deployment and risk management arrangements. Actions were clearly recorded and communicated, monitored and reviewed to ensure improvements had been embedded into practice. This approach contributed to a sustained reduction in falls and improved outcomes for people.

Learning was shared and embedded through daily operational discussions, handovers and team meetings, ensuring staff remained informed of emerging risks and changes in practice. Staff completed reflective discussions and were encouraged to consider how their practice affected outcomes for people. One staff member told us, “I feel the managers manage incidents quite well, we learn together, we’re not perfect. Every day is different.”

We saw numerous examples where learning was translated into action. Following an incident where monitoring equipment had not been positioned correctly, resulting in a delayed response, the registered manager introduced additional checks and reinforced expectations through handovers, supervision and oversight processes. This learning was shared across the service to reduce the likelihood of a similar incident occurring again.

The provider took a proactive approach to monitoring the quality and safety of care. Effective and robust oversight enabled the management team to identify emerging concerns, respond quickly and drive improvements before issues had a wider impact on people.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

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. Records showed safeguarding concerns were referred appropriately and information was shared with partner agencies when required.

People told us they felt safe living at the home. Comments included, “I am safe and secure here in my lovely room,” and, “It's very safe here and if anything is happening outside on the main road or street area, they close the building so no one can get in.” One relative told us, “My [family member] is very safe here, absolutely.”

Staff were able to explain how to protect people from abuse. Staff understood the importance of documenting and reporting their concerns and had completed safeguarding training relevant to their role. Safeguarding policies were accessible and information on how to raise concerns was displayed throughout the home.

The provider ensured people were supported in line with the Mental Capacity Act 2005 (MCA). People's capacity to make decisions about their care was assessed when required and, where individuals were unable to express their wishes, relatives or appropriate representatives were involved in best-interest decision-making. Where restrictions were required to keep people safe, authorisation was sought in line with the Deprivation of Liberty Safeguards (DoLS). Leaders understood recent legislative changes and were supporting staff to apply these in practice.

The provider always worked well with people to fully understand and manage risks by thinking holistically. Staff provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them.

People were supported to make decisions about the risks they were willing to take and the outcomes they wanted to achieve. The provider took a positive approach to risk management, focusing on enabling people to continue doing the things that mattered to them rather than restricting opportunities because risks were present. The provider gave examples of the positive difference this made to people’s quality of life.

Staff worked proactively to understand the individual factors that influenced people's wellbeing, behaviours and safety. Where risks were identified, personalised strategies were developed to reduce the impact on people whilst maintaining important relationships, meaningful experiences and choice. This demonstrated a least restrictive approach to risk management.

The provider went to considerable lengths to ensure people with complex physical, cognitive and emotional needs could continue to access opportunities that were important to them. Detailed planning, individual risk assessments and additional support enabled people to participate safely in community activities and experiences that promoted inclusion, wellbeing and quality of life. People were not excluded from opportunities because of the complexity of their needs.

Staff recognised that risks changed as people's needs and circumstances changed. Information gathered through observations, monitoring and ongoing review was used to adapt support and introduce measures that promoted people's safety whilst maintaining their independence and control.

People were supported to take positive risks safely and remain at the centre of decisions about their lives. Risk management focused on enabling people to achieve outcomes that mattered to them, maintain relationships and access meaningful opportunities while remaining safe.

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

The environment was managed in a way that reduced risks to people and promoted their independence. The home was clean, well maintained and designed to support people to move around safely, including people living with dementia. Communal areas were welcoming and decorated to create familiar, engaging spaces for people, and the provider continued to invest in the environment through plans to develop additional themed areas within the home. People's bedrooms were personalised with their own belongings, photographs and furnishings, helping them feel comfortable and maintain a sense of identity.

Bedrooms, bathrooms and communal areas were spacious, accessible and suitable for people using mobility equipment. We observed the home was clean throughout, with clear corridors and escape routes free from obstructions, supporting people to move around safely and independently.

Routine safety checks were completed, and systems were in place to maintain the premises and equipment. Fire safety arrangements were effective, with regular reviews of personal emergency evacuation plans (PEEPs) and prompt action taken when information required updating. Equipment used to support people, including hoists, was serviced and maintained in line with legal requirements. The kitchen and food preparation areas were clean, well maintained and managed safely.

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

The registered manager took a strategic approach to recruitment, ensuring the team had a diverse range of skills, knowledge and experience reflective of the needs of people using the service. Staff brought together different areas of expertise which complemented one another and strengthened the support available to people. Recruitment processes were thorough and completed in line with relevant legislation and regulatory requirements, helping to ensure people were supported by suitable staff. Updates about recruitment were shared with people using the service and their relatives, helping them feel informed and involved.

Staff told us they had been provided with excellent training and ongoing support to develop in their roles. One staff member told us, “This job is a huge learning curve for me. It’s been fantastic for me to be able to learn.” Staff development was robust, with the registered manager continuously monitoring the impact of training on practice. Regular learning sessions were used to reinforce learning and explore a variety of topics relevant to people's needs.

The provider had introduced champion roles, enabling staff to develop expertise in areas that interested them. Staff were given dedicated time to research topics and identify new ways of improving people's quality of life. They shared their learning with the wider team, helping to embed positive changes across the service. The provider shared examples of this approach leading to positive outcomes for people.

Where poor performance was identified, the registered manager addressed this promptly. Reflective practice was actively encouraged, creating opportunities for staff to learn, develop and continually improve the support they provided.

Our observations during the assessment found there were consistently sufficient staff available to support people safely and in a timely and person centred way. One person told us, “They are always around, always helpful." Another person told us, “I don’t think you could get better staff.”

The provider used a dependency tool to inform staffing levels but remained flexible in its approach. Clinical and nursing support staff were not included within the core staffing numbers, meaning there were often additional staff available to support people and spend meaningful time with them. This meant people received support from a skilled and well-supported workforce with the time, knowledge and expertise to meet their individual needs. This helped promote positive outcomes, consistency of care and improved people's quality of life.

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

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

The clinical team took a proactive approach to medicines optimisation and used medicines as part of a wider strategy to improve people's health, wellbeing and quality of life. Staff worked closely with healthcare professionals to reduce reliance on sedative medicines and increase the use of non-pharmacological approaches for people experiencing distress and behaviours associated with dementia. This resulted in a significant reduction in certain types of medicinesuse, alongside reductions in falls-related injuries and distress. People became more alert and engaged, spent more meaningful time with their families and experienced improved wellbeing. Staff also reported feeling more confident using therapeutic approaches to support people.

The leaders continually reviewed the effectiveness of medicines alongside people's changing needs and circumstances. They demonstrated a strong understanding of the potential benefits and risks associated with medicines and worked proactively with healthcare professionals to review prescribing, respond to side effects and ensure treatment remained appropriate. This included recognising when medicines may be contributing to changes in behaviour, wellbeing or safety and seeking timely clinical review.

Systems were in place to support the safe management of medicines. Appropriate controlled drug procedures were followed. Regular medicines audits and staff competency assessments were completed to monitor practice, identify areas for improvement and provide additional support where needed. The service had clear and exceptionally detailed PRN (as required) medicine protocols, ensuring staff had comprehensive guidance on when medicines should be administered and how people's individual needs should be supported. Clear arrangements were also in place for covert administration, supported by appropriate consent processes, best-interest decisions and risk assessments to ensure medicines were administered safely and in line with legal requirements.

The provider's approach went beyond the safe administration of medicines and focused on achieving the best possible outcomes for people whilst reducing unnecessary medicines wherever possible.