Cliftonville Care Home

Updated 7 December 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by two inspectors, a specialist advisor (a registered nurse) and two Experts by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Cliftonville Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Cliftonville Care Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was not a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spoke with 11 people who used the service and 12 relatives about their experience of the care provided. We spoke with 11 members of staff including the Group Operations Director, the manager, two nurses, five care workers, a housekeeper and the chef. We also spoke with a professional who visits the service.

We reviewed a range of records. This included 12 people’s care records and multiple medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 7 December 2022

About the service

Cliftonville Care Home is a residential care home providing personal and nursing care for up to 106 people. The service provides support to older or younger adults with a diagnosis of dementia or physical disability. At the time of our inspection there were 59 people using the service.

Cliftonville Care Home provides accommodation across three floors with communal lounge and dining rooms on each floor. One of the floors specialises in providing care to people living with dementia. The upper floors can be accessed via two lifts. All bedrooms have private en-suite facilities.

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

The providers systems and processes to monitor oversight of the safety and quality of the service had not always been effective in identifying some concerns we found during inspection, including, some areas of safety in the environment. The provider was responsive to the concerns raised and made the required changes.

People were mostly protected from the risk of infection and we found the home was clean and odour free. However, the manager had not ensured COVID-19 testing for visiting professionals had been adhered to as per government guidance. Government guidance has changed since our inspection and testing is no longer required.

Individualised risk assessments were in place and strategies to reduce risk were planned into care and recorded for staff guidance. There was a system in place to review accidents and incidents and prevent reoccurrence. Positive risk was supported and people were encouraged to be as independent as possible.

Systems and processes protected people from the risk of abuse, staff knew how to raise concerns to safeguard people. People told us they felt safe.

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.

There was a robust system in place to ensure staff were recruited safely. Although there were enough staff to meet people’s needs, people found the high use of agency staffing at times unsettling. The provider had listened to people’s concerns and was actively recruiting permanent staff.

Medicines were administered, stored and disposed of safely. Staff were trained and competency checked and ensured people received their medicine when they needed it.

The provider and manager understood the duty of candour and were open and honest when things went wrong. There was evidence of feedback sought from people and staff, both felt listened to and improvements were made.

The provider worked in partnership with healthcare professionals to ensure people’s needs could be met.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 22 December 2021) and there were breaches of regulation. The service remains rated requires improvement. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We received concerns in relation to the safety and managerial oversight of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

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

Follow up

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