Archived: Clitheroe Care 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 requires improvement. At this assessment the rating has changed to 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 ensured incidents were investigated and reported. When an incident occurred, learning was communicated with staff in a timely manner using a digital messaging service. Staff logged incidents appropriately, and detailed investigation records included root cause analyses, actions taken and lessons learnt. The registered manager kept a log to track incidents and support analysis of themes and trends.

The provider was open and transparent when incidents occurred. We saw evidence information was shared with the relevant agencies, and relatives received assurances and a sincere apology when harm occurred as a result of an incident.

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.

The registered manager worked with people and relatives to establish a plan of care prior to people moving into the home. Pre-assessment paperwork was detailed and captured information about people’s needs and preferences, with consideration given to whether they would be compatible with others living at the home. Staff confirmed information about new referrals was shared with the team.

People had access to the service user guide, which helped prepare them for their move to Clitheroe Care Home.

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.

The provider had clear safeguarding systems to protect people from abuse and neglect, and these were communicated effectively with staff. Staff had up to date training in safeguarding and had their knowledge checked in supervisions. Information, including the local authority contact details was available in the staff room, for ease of access.

A safeguarding log had been implemented to ensure appropriate action was taken in response to concerns. It had recently been updated to ensure local authority reporting thresholds were checked, as per good practice.

When receiving care and treatment, people can only be deprived of their liberty with the appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act (MCA) 2005. We checked how the provider managed DoLS within the home.

The provider ensured DoLS were in place for the relevant people. Renewal dates were monitored, and conditions were reviewed when appropriate to do so. A relative told us, “The previous home [person] was in said they didn’t have capacity to make decisions for themself. I disagreed and spoke with the registered manager. They no longer have a DoLS in place, I am very grateful for the time and understanding shown by [registered manager].”

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.

Staff received a training in subjects such as dysphagia awareness, pressure ulcer prevention, diabetes and falls prevention to help support their understanding of risk.

The registered manager ensured risk assessments had a good level of detail, were person-centred, and allowed people to do the things that were important to them. A person living at the home enjoyed drinking alcohol, others liked to go out independently. The appropriate risk assessments were in place to ensure this could be done safely.

When people communicated their needs, emotions or distress, staff could manage this in a positive way that protected people’s rights and dignity. A relative said, “Staff are so good with [person], and always seems to be able to anticipate when they may be getting upset and are in need of more reassurance.” Care plans included detailed information about potential triggers, signs of distress and the required responses. For example, approaching people gently and validating their feelings, or providing emotional support.

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 provider ensured facilities, equipment and technology were monitored and well-maintained. During our inspection, we observed the environment to be mostly safe and secure. A maintenance person was available to conduct scheduled maintenance or repairs, and regular safety checks were in place. External servicing was carried out in the required timeframes.

The provider had effective arrangements to manage the risk of fire. Staff received annual fire safety training and attended drills and practice evacuations. Fire safety measures such as emergency lighting, evacuation equipment and extinguishers were in place, and routinely checked.

However, we observed 2 fire doors were not fully closing, rendering them ineffective in the event of a fire; and a door plate was missing, increasing the risk of trips or falls. Following feedback, the provider took immediate action to have the fire doors fixed and door plate fitted.

The provider made sure there were enough safely recruited, 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.

The provider had systems in place to recruit staff safely, and robust inductions helped ensure they had the capabilities to meet people’s needs. There were several entries in induction records where concerns with staff competence had been identified. The registered manager had implemented appropriate support, to help staff make the required improvements before completing their probation period.

Staff had the right qualifications and skills to deliver safe and effective care. Observational competency checks had recently been introduced to assess staff members’ understanding and practice in areas such as, IPC, moving and handling, recognising distress, dignity, reporting of incidents and interaction with others. Records evidenced staff had access to a good level of training and support to develop themselves and received regular supervisions.

Managers used a dependency tool to assess required staffing levels, based on people’s individual needs. However, we received mixed feedback about staff numbers and observations showed staff were not always present in communal areas. One person living at the home said, “Sometimes there is no one about. It’s ok for me but some of the other [people] do need an eye keeping on them.” Another added, “I haven’t had to call [staff] often, but they do respond quickly when I press the buzzer.”

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 provider had an effective approach to assessing and managing the risk of infection. The home was observed to be clean and tidy, and housekeeping staff were available daily to support the team. Quick response (QR) codes had been introduced to log cleaning tasks in real time, improving oversight.

Staff had access to IPC training, and senior managers carried out robust IPC audits. Personal protective equipment, soluble laundry bags and hazardous waste bins were provided to promote good levels of hygiene.

People were supported to maintain their own personal hygiene, in line with their needs and preferences. A relative told us, “[Person] needs a bed-bath every day and receives one. Staff make sure [person] has their hands and face washed, their mouth is clean, their hair is brushed, and they have clean nightwear.”

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.

The provider’s medicines policies and procedures followed current legislation and best practice; and medicines were recorded, stored and disposed of safely, including controlled drugs. If concerns with medicines management were identified, the provider took action to make improvements. A healthcare partner told us, “The provider promptly conducts investigations into incidents and works closely with the medicines management team to improve systems and processes.”

A digital system had been developed by the provider to record medicines as they were received into the home, administered or returned to the pharmacy. The system alerted staff when medication was due, to help prevent delayed or missed medicines. The registered manager explained the system had resulted in several improvements to medicines management and oversight, and was being continually reviewed and refined.

Clear person-centred guidance was in place to support the safe administration of medication, including when required medicines. Guidance included information about recommended dosages and frequency, people’s administration preferences and the signs and symptoms for staff to observe.