Clifton Care Services improved from Requires Improvement to Good overall, with previous breaches of regulations 11 and 17 now resolved and people receiving safe, effective, caring and personalised care. However, well-led remained Requires Improvement as the provider's quality assurance framework did not consistently identify documentation shortfalls in risk assessments, mental capacity assessments and care plans.
Concerns (5)
moderate
Governance
: “The provider's quality assurance checks did not consistently identify shortfalls or recognise how improvements could be made.”
moderateRecord keeping: “risks related to the use of bedrails were not consistently documented within people's care plans. For example, how the risk of entrapment was to be minimised.”
moderateCare planning: “one person's mobility assessment referenced that they required the support of a hoist. Information was not clear on how staff should safely use a sling when using a hoist.”
minorConsent / capacity: “the mental capacity assessment was not decision specific. We brought this to the attention of the registered manager who took action to address this during the inspection.”
minorMedication management: “The MAR chart for one person identified that medication should be administered in the morning. Daily notes often referenced that staff were administering the medicine in the afternoon.”
Strengths
· Safe recruitment practices including DBS and reference checks ensured suitable staff
· Consistent staff team with rotas planned a week in advance and relatives confirmed punctuality
· Strong infection prevention and control, highly praised support during COVID-19 pandemic
· Staff received induction, regular supervision, training (including dementia care) and Care Certificate support
· Personalised care with 'all about me' profiles and matching of staff to people for rapport building
Quality-Statement breakdown (21)
safe: Assessing risk, safety monitoring and managementNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Staff working with other agencies to provide consistent, effective, timely careNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: How the provider understands and acts on the duty of candourNot rated
well-led: Continuous learning and improving care: Working in partnership with othersNot rated