Clifton House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of the legal regulation in relation to governance at the service.

This service scored 61 (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 did not always create a positive culture. The provider had not worked transparently to ensure concerns with the culture of staff in the home had been actioned and addressed.

Although there were processes in place to ensure there was a positive culture in the home this included ensuring the wellbeing of staff and ensuring staff had received training that gave them the skills and knowledge to promote a positive culture, we could not be assured this was effective.

Not all leaders understood the context in which the provider delivered care, treatment and support.

Both the registered manager and provider had failed to act when a significant incident had occurred in the home, this meant we could not be assured they understood their roles and legal responsibilities. After the inspection the registered manager took the action after we had told them to keep people safe. Although there were clear lines of delegation and staff had their own roles and responsibility, again we could not be assured this was understood as they had not acted and followed safeguarding procedures.

People and relatives felt the home was well managed and staff were happy with the support they received.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

There was a whistleblowing policy in place and the service had created an environment where staff were able to speak up and raise concerns when needed. In the office we saw information signposting staff where to go for support and the processes to follow. Staff were aware of these procedures.

The provider valued diversity in their workforce.

There were procedures in place to consider staffs’ individual needs, this included considering staff’s diverse needs and treating all staff fairly and equitably. Staff felt they were treated in an inclusive way.

There were not always effective systems in place to make changes and identify areas of improvement.

The system in place to ensure people were protected from potential abuse and harm was not followed and not effective in identifying when action was needed. When the home had been alerted to a safeguarding concern, they had not acted to keep people safe.

There were other audits in place which monitored the care people received, including medicines management and the safety of the environment. There was also a system in place to monitor and review incident and incidents that had occurred. As all incidents had not been reported this system was therefore not effective to ensure appropriate action was always taken.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

There were systems in place to ensure the provider worked in partnership with other agencies, and this ensured positive outcomes for people and improved care.

The provider did not always focus on continuous learning, innovation and improvement across the organisation.

The systems in place were not effective and had not identified all concerns and drive improvements, which meant learning opportunities were missed.