Clifton View 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

We have identified breaches in relation to safe care and treatment, and staffing. Safety risks to people were not always managed well. Shortfalls in the management and oversight of falls, medicines and equipment had left people exposed to the risk of harm. There were not always enough staff available to support people with their identified needs. Managers had reviewed staffing levels, but not listened to staff when they had raised concerns around feeling unable to respond effectively to people’s needs. Staff had not always received support through supervision and appraisal to support their continuous learning and improve their working practice. Managers had assessed and reviewed safety risks to people and made sure people, and those important to them, were involved in making decisions about how they wished to be supported to stay safe. Staff received relevant training to meet the range of people’s needs at the service. People and those important to them were supported to understand safeguarding and how to raise concerns when they didn’t feel safe. Staff understood their duty to protect people from abuse and knew how and when to report any concerns they had to managers. When concerns had been raised, managers reported these promptly to the relevant agencies and worked proactively with them, to make sure timely action was taken to safeguard people from further risk. Managers made sure recruitment checks were undertaken on all staff to ensure only those individuals that were deemed suitable and fit, would be employed to support people at the service. We have asked the provider for an action plan in response to our concerns.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their relatives felt able to speak up if they had a concern. They also felt improvements would be made to their care if needed. One relative told us, “I'm happy with the place. I know if there are any issues I can speak to the staff in the office, and they are dealt with” People and relatives told us that if an incident happened; staff included them in discussions, so it did not happen again. One relative told us, “I'm happy that my family member is looked after, and they keep us updated all the time either whilst there or via a call.”

Some staff members told us that they had not always received regular reflective supervision sessions to review what was working well, and what could be improved at the service. This impacted on their confidence in their colleagues knowledge and skills at times. One staff member told us, “My supervision has only been done once, I have been here a year and only recently done supervision.” The nominated individual and deputy were responsive to the concerns we shared during the assessment. They advised they had reviewed staff meetings and supervision frequency with team members to encourage them to raise concerns.

We saw from recruitment records that some staff had not received a probationary review, or regular appraisals and supervision after being employed at the service. These meetings ensure the registered manager can be assured of the quality of their staff group and allows staff to raise any concerns or training needs they have identified for self-development. There were processes in place to review incidents and then make improvements. Staff were provided with the opportunity to reflect after incidents, to ensure learning and improvement could occur. Staff meetings allowed staff to share their opinions on what was working well, and what could be improved at the service. A member of staff told us, “I am involved in the meetings and feel able to share feedback.” There was a provider policy on the duty of candour. This policy guided the registered manager or nominated individual to tell the person (or, where appropriate their advocate) when something has gone wrong. We reviewed complaints that had been made and saw this policy had been followed.

One relative we spoke with felt communication between the service and themselves could be improved. They told us, “The one thing that could be better is communication. We don’t always get told if my family member has been unwell, for example when there was an outbreak of sickness, that kind of thing.” Another relative told us they were concerned when their family member had been prescribed antibiotics and they hadn’t been informed by the service at the time that they were unwell. Other relatives told us that communication between the care home staff and health providers was good quality. One relative told us, “The relationship between the care staff and the healthcare team on this floor is good. I feel they encourage my family members independence; the staff are all very caring.” Another relative told us, “The falls team came out and sat and talked with the registered manager. They disagreed with some things the external team said as they felt they knew our family member better which was helpful for us.”

Staff had good knowledge of which health and social care professionals supported which people. Staff were able to explain when these professionals visited, and what type of support they offered. One staff member told us, “They loved seeing the changes in people, seeing them improve in their mobility from when they moved in.” Staff knew how to monitor people’s health conditions, to ensure timely referrals were made to other services. For example, where a person had experienced weight loss and a decrease in appetite and been referred to a dietitian.

We requested feedback from partners but received no feedback about Clifton View Care Home. We received no information to indicate any concerns.

Where people required external health and social care support, documentation showed that referrals had been made. For example, we saw referrals had been made for occupational therapy where people required equipment. Referrals for specialist input with support for people living with dementia or sensory needs had been made to external health teams . However, we saw the guidance given by these teams had not always been implemented or updated in people’s care plans. Staff kept clear summary documentation on people’s holistic needs. If the person required a hospital admission, this document could go with them to the hospital. This meant hospital staff would have clear guidance on how the person liked to be supported.

People and their relatives told us they felt safe from abuse or harm. One relative told us, “I do feel my family member is safe with staff as they have someone with them when they walk and a sensor mat in front of them which triggers when they stand up.” People and their relatives told us that there were no unlawful restrictions imposed on them. They were free to complete their own routines and live their lives as they wished. Some people would be at risk if they did not have continuous supervision and control, where this was the case, we saw staff had applied the suitable Deprivation of Liberty Safeguards. These safeguards ensure people who cannot consent to their care arrangements in a care home or hospital are protected if those arrangements deprive them of their liberty. One relative told us, “I have heard the staff ask for consent. They do encourage my family member to do what they can.” Another relative told us, “My family member has never complained about the staff rushing them or not seeking their consent. I think they do encourage them to be independent, give them the opportunity to try to do things for themselves.”

Staff were less confident in using the provider whistleblowing processes if they felt concerns were not being responded to. Some staff gave feedback they had raised concerns with the management team which they felt had not been addressed. These concerns related to staffing, feeling unable to respond to call bells and sensor alarms in a timely manner during night shifts and some concerns around the culture in the service. We shared these concerns with the nominated individual during our assessment for them to investigate. They provided a full response and reassurance regarding the concerns. They agreed to work openly with the staff team and ensure communication was improved moving forwards. Staff understood how to respond to allegations of abuse. Staff told us that they had no concerns, but if they did, they were confident the management team would act appropriately. One staff member told us, “I know how to report safeguarding concerns. I would report to the manager or if the manager was accused of abusing someone, we would refer to the safeguarding agency.” The registered manager understood how to respond to allegations of abuse. They had a clear process of how to investigate and keep people safe. Staff knew where to find the safeguarding policy. They were aware of the policy guidance and knew how to follow it to keep people safe from potential abuse.

We saw people, relatives and staff had positive relationships. People were being supported by staff who were kind, caring and empathetic towards people and their relatives. There was open and positive communication, and we saw no evidence that people were at risk or fearful of the staff team.

If an allegation of abuse was made, there were appropriate policies in place to guide the staff team. Records showed that incidents were referred to the local authority safeguarding team if needed. People were kept safe when they went out into the community. The activity co-ordinators regularly arranged trips and activities for people to external venues. There were clear plans in place to ensure people were supported in a safe way when they were out of the service. On the second day of our visit, several people enjoyed a day trip to Sea World in Birmingham, which they told us they all really enjoyed. One relative told us, “There are trips out, they have been to Skegness, the Sea Life Centre, they go to coffee mornings at the church.”

People told us that staff understood their needs well and offered support to keep them safe. One person told us, “I feel well looked after here by the staff, much less anxious than when I moved in.” People and their relatives told us that they were able to communicate their needs, to ensure they received the right type of support. One relative told us, “Initially my family member had lost weight as they had been very unwell prior to admission. We thought they wouldn't pull through, but they are eating now, and their weight has stayed consistent.” Another relative told us, “When my family member started to have falls, they moved them into to a different room closer to the office so if the sensor triggered staff were there quicker.”

Some staff shared their concerns around the low staff numbers at night impacting on the timeliness of their response to call bells and sensor alarms. We saw records where people had sustained injuries and had been taken to hospital following these injuries. We raised the staff concerns and discussed the safeguarding records with the deputy manager and the nominated individual, who reviewed the staffing numbers and staffing allocations. They agreed to add extra staff to the rota to ensure risks were mitigated and safe care and support for people was provided.

We saw people were supported safely during our time at the service. We saw staff were timely in their responses towards people to ensure any distress did not escalate. Our observations raised no concerns regarding involving people to manage risks at this service.

People’s needs were clearly documented in their care plans, so staff had clear guidance on a person’s mental, physical, and social needs. Staff knew how to support people to manage risk. However, we received concerns from staff regarding their ability to respond effectively due to low numbers. For example, where people living with a risk of falls required the support of staff for mobilising or moving from a chair to a bed with the assistance of equipment. We were concerned about some of the sensor equipment in place to reduce the risk of falls, not being maintained. This lack of equipment maintenance had left people exposed to the risk of harm. We raised this with the deputy manager at the time of our visit and this was rectified. We found personal emergency evacuation plans were incorrect for some people in the service, with the wrong bedroom number and incorrect details regarding the evacuation needs for people. Although staff had clear processes in place for how to respond to an emergency and the evacuation processes to follow. The deputy responded to our concerns raised on site, and ensured these documents were reviewed and updated to fully consider the unique needs of people. Staff had received training on how to support people’s individual needs. Some people at the service could become distressed due to their dementia diagnosis. Staff had received training on how to support people when they became upset or anxious. People’s communication needs were clearly recorded. This allowed staff to understand people’s needs and wishes to support them to stay safe.

People showed the inspection team their bedrooms, they explained that they felt their bedrooms felt safe to them. We saw people’s bedrooms had been personalised to their own tastes. One relative told us, “They asked my family member what colour scheme they wanted, then painted it. We could then take some of their own furniture in there, to make it homely for them.” People and relatives told us that the call bells in their bedrooms were working and accessible. This meant they could request staff support if needed. One relative told us, “I think in the main my family member is safe. I think their main risk is getting up in the night and falling.” We saw this person had a working sensor and accessible call bell in their bedroom.

Staff knew how to monitor the safety of the environment, and where to report any maintenance concerns to. The management team described a clear process for monitoring environmental safety concerns. The environment was kept safe, by regular checks and maintenance. We saw there had been regular checks to ensure the home was safe in the event of a fire (for example, by checking the alarm systems.) Systems were in place to ensure the water quality was maintained to reduce the risk of water-borne bacteria (like legionella.) The gas heating system was regularly serviced to prevent harm to people. Staff knew how to respond in the event of an emergency evacuation. For example, if a fire alarm sounded, staff could explain how people would be supported to move into a safe space.

A number of the bedrooms we observed contained furniture which was not secured correctly to the wall as required under Health and Safety Executive (HSE) guidance. The deputy manager and nominated individual completed a full audit of all bedroom furniture following our visit to ensure this was secured as required, to reduce the risk of harm to people. The home was safe in the event of a fire. Corridors were clear of any blockages, allowing people to follow easy to read escape routes. Staff had access to fire-fighting equipment Windows were unable to be opened wide. This safety feature prevents people from falling or climbing out and is in line with guidance from the HSE.

People had access to call bells to call for support if needed. However, documentation showed some of these call bells or linked sensors for falls management had not been regularly maintained, to ensure they were working and effective. We found a person’s bedroom where the sensor had been reported as faulty by staff in the previous month. This had been added to the maintenance log and not repaired. This left the person at risk of harm, as they had been identified as being at risk of falls. The deputy manager ensured this sensor was replaced when we raised this with them on our site visit.

People and their relatives gave mixed feedback in response to staff numbers but raised no concerns about staff knowledge, skills, and their caring approach. One relative told us, “The staff do seem well trained. Sometimes over holiday periods they can be a bit short staffed. The Senior staff seem to have been there a long time. You see regular faces, then new faces. Some staff leave or move to other floors in the service.” Another relative told us, “I think there are times they are short staffed especially over the summer with holidays, but they are still caring.” Another relative told us, “At weekends there are less staff and not the regular staff you see in the week but that's understandable, they need a break. They are good people.” Another relative said, “You generally see the same faces, some new staff and I think they help out on other floors if they are short staffed.” Another relative told us, “The regular carers are wonderful, all the staff are really. There are some new staff, some changes. Recruitment is difficult for them.” Other relatives told us staff were well trained and knew how to meet their family member’s needs. One relative said, “The staff are well trained, they are really good with my family member.” While another relative said, “I feel my family member is very safe and I'm happy they are happy, it’s such a relief.”

Some staff we spoke with expressed concerns around low staffing impacting on their ability to respond in a timely manner to call bells and sensor alarms. Staff explained this was a particular concern during the night shift when staffing numbers were lower. They explained how they felt this was a risk to people, particularly when they might be waiting for a member of staff to move from another floor to assist or to cover rest breaks. Staff explained they had raised their concerns with the management team but had not felt these had been listened to. Staff told us they had not always received regular opportunities to meet their line manager on a one-to-one basis for supervision. These meetings should offer staff the opportunity to feedback about their experiences and request further guidance and training if needed. Some staff felt the induction process in place at the service could be improved, to offer a better quality of training for staff new to the social care profession.

We saw from staffing rotas there were not always sufficient staff available to provide support to people safely. Staff were not always deployed effectively around the building, to provide timely support for people. For example, 16 of the 20 people living on the ground floor had been identified in the dependency tool as being at ‘high risk’ with 6 of these people needing the assistance of two staff for their care and support needs. We saw the staffing rota for the night shift had only one senior and one member of care staff allocated to the ground floor to support people. We raised this with the nominated individual and deputy manager, who reviewed the dependency tool for the service and the staffing allocation. They added an extra member of staff to the rota for this floor to provide assurance that people’s needs could be more effectively met. We saw staff were suitably trained to complete their roles. Staff used their training and skills to respond effectively to people’s needs.

Although we staff had received suitable training to do their role, the management team had not ensured there were always suitably skilled staff working. Feedback we received from staff and review of the rotas indicated that some staff lacked the skills and knowledge to support people safely. For example, with manual handling needs and the use of specific equipment to assist with this. Once staff were trained, there were clear ongoing processes to assess their competency. If needed, further support and training was then given to improve staff skills. If staff were not providing the expected level of care, there were clear processes to monitor and improve their performance. Safe recruitment processes were followed. For example, previous employers were contacted to give references on the staff member. Staff had regular Disclosure and Barring Service (DBS) checks. These check the police database for convictions or warnings that may impact the staff members safety to work with people.

People told us that the home was kept clean. One relative told us, “It’s clean, the domestic staff team are lovely, we can't complain.” People told us that staff wore personal protective equipment as needed.

Staff knew what personal protective equipment they should wear and when. Staff knew how to put on and remove this equipment, in a safe way. This protected people from the spread of infection. Staff understood the risks of COVID-19, how to spot symptoms and what action they should take to keep the person and others safe. Staff had received food hygiene training. They were able to explain what actions they took to reduce the risk of food borne infections.

There were some communal bathroom areas of the service which required repair and deep cleaning. These had not progressed in line with the infection prevention and control audits in place for the service. Some people at the care home used equipment (like walking frames, shower chairs or hoists). We saw some of these pieces of equipment were noted to be in need of deep cleaning. This had not been identified in the regular audits completed by the registered manager. The deputy manager and nominated individual were responsive when we raised our concerns and ensured these shortfalls were responded to. They implemented more effective daily audits to ensure that infection prevention and control measures and maintenance works completion were robust moving forward. The home was safe in the event of a fire. Corridors were clear of any blockages, allowing people to follow easily to read escape routes. Staff had access to firefighting equipment throughout the home and fire alarms were throughout the building. We saw the kitchen was managed in a hygienic way to ensure people were not exposed to the risk of food borne infections. The most recent check from the food standards agency, had rated the service 5 stars in April 2024.

There were clear processes and policies in place, to ensure people were protected from the spread of an outbreak or infection. If an infection outbreak occurred (for example diarrhoea and vomiting), there were clear processes in place to reduce the risk of this spreading to other people at the service. Staff had received training in infection control, how to put on protective equipment and how to keep people safe in the event of an infection outbreak.

People and relatives told us that staff were well trained in medicines management, and they were involved with reviews of their medicine. One person said, “The staff are trained yes, and seem confident, and there seems to be a continuity of the same staff.” People and relatives told us that staff gave their medicines at regular times, and as their prescription required. One relative told us, “My family member is a diabetic and their medication is given correctly.”

Staff were able to explain how they supported people to take their medicines safely. One staff member said, “I am confident about my medicines practice. I have been here for many years. I understand my role.” Staff knew who to report medicine concerns to. For example, if they felt a person’s medicine was no longer effective, they understood where to document this, and which health professionals to contact.

Some people required ‘as needed’ medicine and staff had clear written guidance on how this should be administered. For example, multiple people required pain relieving medicines to be administered ‘as needed.’ We saw the documentation for these medicines had not clearly explored the reasons why people had required these medicines, and ‘general pain’ had been recorded on multiple occasions. This left people at risk of being given medicines without staff recording the impact on a person’s pain levels and without requesting a review from the prescriber. The deputy manager responded to our concerns on site and reviewed the ‘as needed’ medicines documentation and shared the updated processes with the senior staff within the service. One person required their medicines to be administered covertly. Covert medication is when staff administer medicine without the persons’ knowledge or consent; for example, by disguising it in food or drink without the person knowing. We found the relevant mental capacity assessment and decision-making documentation for this was not in place. The deputy manager responded to our concerns on the first day of assessment and ensured they sought the correct documentation for these medicines for this person. This was confirmed as being complete when we returned on day two. Prescribed creams containing medicine were left in multiple people's bedrooms. The risk of these being applied to the wrong people or a person ingesting these was high. We asked the deputy manager for these to be stored securely with clear dates of opening recorded on the labels, after the first day of assessment. We checked and this had been completed when we returned on day two. Staff kept clear records of when they had given prescribed medicines. We saw medicines were given as prescribed. Staff did regular checks of the amount of medicine in stock. This ensured that suitable stock levels were always in place, and more medicine could be ordered from the pharmacist as needed.