CQC report explained · a residential care home
What the CQC found at Arncliffe Court Care Home
Rated Inadequate: inspectors found the home performing badly and the CQC has taken enforcement action.
What inspectors found, June 2022
Rated Good; inspectors found safe, effective and well-led care, with isolated medicines issues and some safety checks fixed during the visit.
This was an unannounced focused inspection on 24 May 2022. Two inspectors and a medicines inspector spoke with people, relatives, staff and managers. They observed care and checked care records, medicines records, staff records and management records.
The home was rated Good for Safe, Effective and Well-led. Inspectors found that risks were assessed, staff were suitably trained, people received the care and support they needed, and quality checks had improved.
There were some isolated medicines problems. One medicine was given after food instead of before food, and the process for giving medicines to someone away from the home was not followed. The manager acted immediately. Some doors containing hazards were also unsecured, and some emergency evacuation plans needed updating. These issues were dealt with during the inspection.
The overall rating improved from Requires Improvement at the previous inspection. This report only inspected Safe, Effective and Well-led. Ratings for Caring and Responsive were carried over from the previous inspection.
Risk management
Care plans and monitoring records gave staff guidance about risks such as diabetes, epilepsy, repositioning and food and fluid intake.
“Risk assessments were completed, and risk management plans provided staff with guidance on how they were to safely manage risk.” from the report
Staffing and training
Inspectors found enough suitably skilled staff. Recruitment checks were completed, and induction and training had been strengthened, including for agency staff.
“People's needs were met by the right amount of suitably skilled and experience staff and robust processes were followed to make sure they were fit for the job.” from the report
Consent and best interests
The home had improved its work under the Mental Capacity Act. Best-interest decisions were recorded and staff understood people's legal safeguards.
“Best interest processes were now being followed.” from the report
Improved oversight
The provider had acted on the previous inspection findings. Audits and checks were being used to manage risks and make improvements.
“The systems to assess, monitor and review the quality and safety of the service were now used effectively to manage performance and risk and drive improvement.” from the report
Environmental safety checks
needs fixingSome doors to rooms containing hazardous items were not secured. The manager corrected this when inspectors raised it.
“We did however note on one unit doors were not secured to a sluice room and storerooms which contained hazardous items.” from the report
Emergency evacuation plans
needs fixingSome personal evacuation plans had not been updated after changes to people's mobility. This was corrected after inspectors raised it.
“However, PEEPs for some people had not been updated following a change which impacted on their mobility.” from the report
- 01How do you check that medicines are given at the correct time, including before or after food?
- 02What procedure do you use when someone takes their medicines while away from the home?
- 03How often are doors, storerooms and other areas containing hazards checked and secured?
- 04How do you make sure each person's personal evacuation plan is updated when their mobility changes?
- 05What is the current rating and evidence for Caring and Responsive, which were not assessed in this inspection?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were carried over. This explanation was written from the published report of 28 June 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2021
Rated Requires Improvement; inspectors found progress in medicines, infection control and the home’s culture, but continuing risks and consent and management failures remained.
This was an unannounced follow-up inspection on 16 and 19 July 2021. Inspectors spoke with people living in the home, relatives, staff and health and social care professionals. They reviewed care records, medicine records, recruitment files and management records.
The home had improved since its previous inadequate rating. Medicines systems and infection control were better, the home appeared clean, and inspectors saw kind and patient support. However, care plans and risk records were not always accurate or complete. Staffing was also described as insufficient at times, with frequent use of agency staff.
Inspectors found that the Mental Capacity Act was not always followed. This meant decisions might not have been made in people's best interests. Management oversight had improved but was still not effective enough, and communication with families was often poor.
The overall rating changed from Inadequate to Requires Improvement. The home was no longer in special measures, but it remained in breach of three regulations and CQC asked for an action plan and said it would monitor progress and return to inspect.
Improved medicines systems
Inspectors found that medicines were being managed more safely. New checks and audits had been introduced, with an electronic system being rolled out.
“The provider had implemented new and robust systems to ensure people received their medicines appropriately.” from the report
Better infection control
COVID-19 infection prevention had significantly improved. Inspectors were assured about PPE, testing, cleanliness, outbreak planning and visiting arrangements.
“We were assured that the provider was using PPE effectively and safely.” from the report
Kind and patient care
Inspectors saw staff supporting people in a caring and patient way. They also saw comfortable relationships between staff and people living in the home.
“We observed support being provided in the home and saw that this was done in a caring, responsive and patient manner.” from the report
Improving atmosphere and leadership response
The new management team responded positively to concerns raised during the inspection. Staff feedback suggested communication within the home was improving.
“There seemed to be a marked improvement in the atmosphere of the home and we saw comfortable relationships between staff and the people living in the home.” from the report
Risk records and care monitoring
seriousCare plans and risk assessments did not always reflect people's needs. Inspectors found missing or conflicting information about pressure care, PEG care and diabetes.
“The systems in place to mitigate risks in respect of people's needs and care were not robust.” from the report
Consent and best-interest decisions
seriousThe home did not always follow the Mental Capacity Act. Some best-interest records were incomplete, so decisions made for people might not have been in their best interests.
“Appropriate best interest processes were not being followed.” from the report
Staffing and recruitment checks
needs fixingAlthough there appeared to be enough staff during the inspection, people, relatives and staff said staffing was not always sufficient. Inspectors also found an issue with a previous employer reference.
“However, feedback received from people living in the home and family members indicated that at times, staffing was not always sufficient.” from the report
Weak management oversight
seriousManagement systems had improved but did not reliably identify or resolve problems. Confidential information was not always stored securely, and governance remained in breach.
“The provider's governance arrangements remained ineffective.” from the report
Poor communication with families
needs fixingMany people and relatives said communication from management was insufficient and that their views had not been sought.
“During the inspection we spoke with people and their families, a significant amount of feedback we received indicated that communication with the management of the home was not effective” from the report
- 01What has been done to correct the problems with pressure care, PEG monitoring, mattress settings and diabetic care plans?
- 02How do you now check that Mental Capacity Act assessments and best-interest decisions are complete and correct?
- 03What staffing levels are planned on each shift, and how often are agency staff used?
- 04How do you check that care plans and risk assessments accurately reflect each person's current needs?
- 05How will you keep families updated and make sure their views are heard?
This was an unannounced follow-up inspection that rated Safe, Effective and Well-led, and also checked infection prevention and control; Caring and Responsive were not rated in this report. This explanation was written from the published report of 11 August 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Arncliffe Court Care Home
6 rated inspections over 3 years: the service has improved, from Inadequate to Good.
- June 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2021Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- April 2021Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- December 2019Requires improvementstayed Requires improvementSafe: Requires improvement
- May 2019Requires improvementup from InadequateSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- March 2019InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- November 2017
Registered with the Care Quality Commission on 30 November 2017.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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