Clair Francis Retirement Home

Updated 30 July 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 included checking the provider was meeting COVID-19 vaccination requirements. 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

One inspector carried out this inspection.

Service and service type

Clair Francis Retirement Home is a ‘care home’. People in care homes receive accommodation and personal care as a single package under one contractual agreement dependent on their registration with us. Clair Francis Retirement Home is a care home without 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 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 commissioners of the service and the local authority safeguarding team. 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.

During the inspection-

We spoke with six people who live at Clair Francis Retirement Home. We also spoke with two relatives. We spoke with the registered manager, one senior care staff, two care staff and a member of the domestic team.

We reviewed a range of records. This included three people’s care records, risk assessments and 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 were also reviewed, including incident records, compliments, quality assurance processes and various policies and procedures.

After the inspection

We continued to seek assurances about people's medicines administration records.

Updated 30 July 2022

About the service

Clair Francis Retirement Home is a two storey adapted building and provides accommodation and personal care for up to 28 older people, some of whom are living with dementia. At the time of the inspection, 19 people were living in the home.

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

Risks to people including those for falls, infection prevention and control, choking, skin integrity, fire safety and malnutrition had been identified. Systems and processes in place helped ensure risks were mitigated or removed.

Staff had training on how to recognise and report abuse and had the skills to protect people from poor care and abuse, or the risk of this happening. The service worked with other agencies to do so. The service had enough appropriately skilled staff to meet people's needs and keep them safe.

People were supported to make decisions that meant risks could be taken, managed in a safe way and were in people's best interests; the policies and systems in the service supported this practice.

Medicines were administered and managed safely. Incidents and accidents were reviewed, and learning was shared across the staff team. Staff had enough personal protective equipment, used this effectively and disposed of it safely. Visitors were supported to visit the service safely.

Oversight, governance and the provider's monitoring systems were effective in identifying and driving improvements. There was an open and honest staff team culture. The reporting of incidents meant changes made helped reduce the risk of recurrences. The registered manager supported staff in a positive manner, was approachable and had an open door policy where staff were listened to and actions taken were effective.

People, relatives, staff and others involved in people's care had a say in how the service was run, and compliments were used to help identify what the service did well. The registered manager and staff team worked well with outside agencies to ensure people received the care and support they needed. Staff felt supported in their roles.

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 (report published 25 March 2022) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

Why we inspected

This focused inspection of the safe and well-led key questions was carried out to follow up on action we told the provider to take at the last inspection. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Clair Francis Retirement 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.