Clifton Manor Residential 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 remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 and embed good practice.

The registered manager spoke confidently about the learning culture within the home. They gave us examples of how incidents, accidents and safeguarding concerns were reviewed to ensure lessons were learned. Incidents were logged, investigated and addressed, with outcomes and learning routinely shared with the team. Records were detailed, timely and demonstrated action had been taken to support improvements.

We observed a flash meeting during our inspection. A flash meeting is a short daily meeting where staff share updates, discuss any concerns and agree actions. Staff openly raised incidents and explored solutions together. For example, staff discussed a recent safeguarding incident and considered whether the behaviour may have been linked to an area of interest for the person. Rather than focusing solely on preventing the behaviour, staff explored ways to support the person to continue the activity safely while reducing any impact on others. This demonstrated a reflective and person-centred approach to learning from events. The registered manager played an active role in facilitating reflection.

Leaders were welcoming and responsive to feedback. Where we identified opportunities for improvement during the inspection, action was taken promptly to address them.

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, including when people moved between different services.

Staff completed pre-admission assessments and gathered detailed information before people moved into the service. This supported continuity of care and ensured the home could meet people’s needs safely. During the assessment, we observed staff understood people’s needs and risks and adapted support when required.

Staff worked with external professionals, including district nurses and GPs, to support safe transitions and ongoing monitoring. Information was shared to help ensure people received care and support that met their individual needs. This included sharing relevant health and care information when people attended healthcare appointments or accessed external services. Positive working relationships with partner organisations supported timely referrals and helped maintain continuity of care.

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.

People were protected from abuse, neglect and discrimination. People told us they felt safe living at the home. Comments included, “I love it here, nothing worries me. You’re in safe hands.” and “I feel safe in my room, a happy sort of place”.

There were robust systems and processes in place to help protect people from harm. Safeguarding policies were accessible and staff had completed safeguarding training relevant to their role and demonstrated a high level of knowledge. Leaders maintained detailed records of incidents, falls and safeguarding concerns, including any actions taken, referrals made and any learning identified. Leaders demonstrated a clear understanding of safeguarding processes and escalation routes. Where improvements to staff practice or provider processes were identified, action was taken and learning was shared with the staff team.

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 and where individuals were unable to express their wishes, relatives or representatives were consulted to support best-interest decision making. When people were subject to restrictions to keep them safe, authorisation was sought in line with the Deprivation of Liberty Safeguards (DoLS).

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

Care plans and risk assessments included clear, detailed information about people’s needs and risks, which supported staff to provide care safely and consistently. Referrals were made to relevant healthcare professionals when required, including for risks associated with choking, falls and skin integrity. People’s care records included guidance for staff on how risks should be managed in a way that balanced safety with individual choice.

Staff showed a good understanding of how to reduce risks while supporting people’s independence. People were involved in discussions about their care and support, and positive risk-taking was encouraged where appropriate. For example, we saw evidence of one person being supported to continue accessing the community despite identified risk. Staff put measures in place to reduce those risks while enabling the person to continue pursuing activities that were important to them. This supported the person’s independence, wellbeing and sense of purpose.

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. Routine safety checks were completed, and systems were in place to maintain the premises and equipment. Fire safety was robust, with regular personal emergency evacuation plans (PEEPs) reviews and prompt action taken when information needed correcting. We noted that people who were in hospital were not marked as absent on the PEEPs documentation. This was addressed immediately. Equipment used to support people, including hoists, was maintained in line with legal requirements. Staff ensured spaces were free from clutter to support people to move around the home safely. The kitchen and food preparation areas were clean, well maintained and managed safely.

The provider was undergoing refurbishment, and we saw some areas had been recently redecorated.

The provider made sure the staff working at the service were skilled and experienced and were receiving effective support, supervision and development.

The service had a robust recruitment process and used a dependency tool to monitor staffing levels. Some of the people we spoke with told us they felt they have to wait for support when staff are assisting other people and that supervision in the lounge can be a problem. One person told us, “They could do with some more staff as they can’t always sit with us in here.” Our observations during some points of the day suggested staffing deployment could be further reviewed to enhance the quality of care provided.

Other people, and their relatives, told us they felt the staffing levels are appropriate. Comments included, “I believe there is full staffing and am not aware of any problems. [My family member] cannot call for help; they are cared for by the clock, with frequent repositioning – staff understand the importance and are diligent in that.”

Staff received regular supervision and appraisals, which were well tracked. Recruitment processes were safe and included Disclosure and Barring Service (DBS) checks and verified references. New staff received structured induction from experienced staff. Staff told us workloads were generally manageable and they felt confident in their roles, with some acknowledging the need for additional staff.

While we found that staffing levels did not have an impact on safety, we shared people’s views with the provider, who increased the number of staff on the day shift by the time the assessment concluded. Similarly, we saw evidence that where additional staff were required on night shift, staffing levels had been adjusted in response. This demonstrated that staffing was monitored and adjusted to meet people’s needs.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The home was clean and well maintained. Staff followed safe personal protective equipment practices and were observed using hand hygiene correctly during walk-rounds. Mandatory infection, prevention and control (IPC) training was completed by staff, and IPC audits were carried out. Clear IPC policies were in place and easily available to staff. Staff told us they understood their responsibilities in relation to infection control and felt confident to follow procedures. We observed staff wearing the correct personal protection equipment and disposing of it in line with best practice. The provider had ensured that the equipment was easily accessible to staff and there was a safe system for disposing waste at the service.

People spoke positively about the cleanliness of the home and told us they particularly valued the laundry service.

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.

There were systems and processes to support safe management of people’s medicines, and people received their medicines as prescribed. We identified 2 creams stored in people’s bedrooms rather than in a secure, locked location, and these did not have opening dates recorded. The registered manager addressed this promptly, and there was no evidence that this had caused harm to people.

Appropriate controlled drug protocols were in place to support safe administration, including second signatures. Medicine audits and staff competency checks were completed regularly by the registered manager, to identify errors or areas where staff required additional support or training. The service had detailed protocols for people with PRN (as required) medicine and covert administration. Relevant consent, best interest decision and risk assessment documentation was in place to support safe decision-making.

One professional told us the home “demonstrates a well‑organised approach to medication management and remains responsive to advice provided during visits. The home has several effective processes in place.”

People told us their medicines were managed safely. One person told us, “They always wait with you while you take anything." We observed medicines being administered in a discreet and safe way.