Archived: Clifton 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 inspection we rated this key question requires improvement. At this inspection the rating has changed to good. This meant people were safe and protected from avoidable harm.

At the last inspection the service was in breach of regulations regarding the safe care and protection from avoidable harm. Enough improvements had been made, and the provider was no longer in breach of 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 service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. One person told us, “I just feel safe, I have never thought otherwise.” The management team investigated incidents, accidents and near miss occurrences to see if anything could be done differently. For example, following a potentially significant incident, involving a person, the management team reviewed their risk assessments and care plans and made changes to minimise the potential for harm.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. When people’s individual needs changed, they were referred onto other healthcare providers without delay. People had care plans based on effective assessments which were individual to them. These were reviewed promptly if changes were noted. If someone moved between services, for example to hospital, the provider had systems in place to ensure the most recent and relevant information was quickly and effectively passed to ensure the person received continuous care. One person told us following a recent incident, their details were promptly passed to healthcare partners for them to be able to make an effective assessment which helped them get rapid access to treatment.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. When it was necessary the service shared concerns quickly and appropriately. Everyone we spoke with stated they knew how to raise a concern if they were worried about anything and were confident, they would be responded to appropriately. Staff had received training on safeguarding and knew how to raise concerns. One staff member told us about the training they had completed and knew how to report incidents of concern in accordance with local protocols. Information on how to raise concerns were available for people, staff and visitors.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People had individual assessments of risks associated with their care and support. These included, but were not limited to, risk of falls and diet and nutrition. Staff were aware of these assessments and knew how to keep people safe. One person told us, “I cannot live on my own. I feel safe here.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, and facilities supported the delivery of safe care. We identified some minor changes which were needed to ensure people remained safe. For example, not all fire exits were clearly identified and not all fire escape routes had appropriate signage to direct people and visitors in the event of an emergency. The provider addressed this immediately and appropriate fire signage was in place by the time we concluded our site visit.

The service 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. People told us staff were available to help and support them promptly when needed. One person said, “I do think that there is enough staff to meet my needs.” The provider followed safe recruitment checks to ensure only suitable persons were employed to support people.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. Although the provider was completing safe checks on the water systems including regular flush throughs of seldom used outlets and annual bacteria checks. They had not commissioned a formal legionella risk assessment completed by a competent person. Such assessments support the safe provision of accommodation for people from waterborne pathogens including, legionella. We raised this with the provider who commissioned an external water safety expert to complete the necessary assessment and any subsequent remedial action. In other areas of the home, we saw the cleaning was not as effective as it should be. We saw several dining chairs where food debris and fluids had not been effectively cleaned. We identified this to the management team who took immediate action to clean the areas, educate staff on effective practices, review cleaning schedules and increase the level of detail in their cleaning checks. However, despite our findings people felt the home was clean and tidy. One person said, “It is nice and clean here,” and a relative told us, “It is spotlessly clean.”

The service made sure medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. People told us they received their medicines as prescribed. One person told us, “I have medication and they never forget to give it to me.” People had protocols in place for the safe administration of PRN (as and when needed) medicines including the prescribed dose, time between administrations and maximum dose within a 24-hour period. Staff felt comfortable and empowered to raise any issues regarding medicines in an open and transparent way. Issues were quickly addressed by the management team to ensure people received their medicines safely.