CQC report explained · a residential care home
What the CQC found at Cliffdale Rest Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm, supported by enough staff and given medicines safely. Some building safety checks were incomplete, but the provider acted immediately to fit suitable window restrictors and complete the fire risk assessment review.
- Effective?
- Good
- People's needs were assessed before they moved in, and staff had the training and supervision needed for their roles. People were supported with food, drink, healthcare and decisions about their care.
- Caring?
- Good
- People were treated with kindness, dignity and respect. They were involved in decisions, supported to remain independent and helped to maintain important relationships.
- Responsive?
- Good
- Care was personalised to people's needs, preferences and communication requirements. People had access to activities, community links and a complaints procedure.
- Well-led?
- Requires improvement
- People and staff spoke positively about the management and the home's vision. However, leadership systems did not consistently identify all health and safety requirements, including window restrictors and the date for updating the fire risk assessment.
What inspectors found, April 2020
Rated Good overall; inspectors found safe, kind and responsive care, but the home's safety checks were not complete.
This was an unannounced inspection following the previous Requires Improvement rating. Inspectors spoke with five people, one relative and 10 staff. They observed care and reviewed care, medicine, recruitment and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. People were supported by enough staff, received medicines as prescribed, and were treated with kindness and respect. Their care was personalised, and people were supported to make choices, maintain relationships and take part in activities.
Well-led was rated Requires Improvement, as management checks did not cover all relevant health and safety requirements. Window restrictors did not meet regulations and the fire risk assessment was overdue for review. The provider acted immediately on these issues, but needed to improve how it checked that safety standards stayed met.
Enough staff
Inspectors found enough staff to meet people's daily needs. Staff had time to interact with people and vacancies on the rota were usually covered by existing staff.
“People were supported by sufficient numbers of staff to have their daily needs met.” from the report
Kind and respectful care
People were treated well and involved in decisions about their care. Staff supported privacy, dignity, independence and continued involvement in the community.
“People were observed being well treated and gave positive feedback about the care they received.” from the report
Personalised support
Care plans reflected people's needs, history, relationships and interests. Staff respected people's preferences and supported relationships between couples and friends.
“People's care was personalised to meet their individual needs.” from the report
Food and drink
People were offered drinks and snacks, and those spoken with praised the meals. Kitchen staff understood individual preferences and modified diets.
“People were observed being offered a range of drinks and snacks throughout the day and everyone we spoke to was complimentary of the meals provided.” from the report
Incomplete safety checks
needs fixingManagement checks did not cover all the necessary health and safety regulations. The provider corrected the immediate problems, but the inspection found that the checking system itself needed improvement.
“However, we identified the health and safety checks being completed did not cover all the necessary regulations, such as window restrictors.” from the report
Fire risk assessment timing
needs fixingThe date by which the fire risk assessment should have been updated had passed. Work had started and the provider completed the review after inspectors raised the issue.
“We also noted the date of when the fire risk assessment needed to be updated by had passed.” from the report
- 01How do you now check that window restrictors and other building safety requirements remain compliant?
- 02When is the fire risk assessment next due for review, and how will you make sure this date is not missed?
- 03What changes have been made to the governance checks since this inspection?
- 04How will you show families that the safety improvements have been maintained over time?
- 05How are individual preferences, relationships and community activities recorded and reviewed in each person's care plan?
This was a planned, unannounced inspection that considered all five CQC questions, including the premises and personal care; the report says Safe improved from the previous rating, while Well-led remained Requires Improvement. This explanation was written from the published report of 25 April 2020 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, March 2019
Requires Improvement; Cliffdale Rest Home provided kind, personalised care, but inspectors found infection-control and management weaknesses.
This was an unannounced, planned comprehensive inspection on 5 February 2019. Inspectors reviewed care, medicines and management records, observed care, and spoke with people, relatives, staff and professionals.
People said they felt safe and happy. Staff were kind, respectful and responsive. Care was personalised, people were supported with food, healthcare, activities and their choices, and staff had suitable training.
The home was not always clean or well maintained. Inspectors found risks from possible infection and cross-contamination, and exposed hot pipework that could cause burns. Some immediate improvements were made after the visit.
The overall rating was Requires Improvement. Effective, Caring and Responsive were rated Good. Safe and Well-led were rated Requires Improvement. The previous Good rating was under a former provider, before the new provider took over in July 2018.
Kind and respectful staff
People described staff as kind and said they responded quickly when help was needed. Inspectors also observed warm, friendly communication and emotional support.
“Staff communicated with people in a warm and friendly manner, and gave people the time they required to answer.” from the report
Personalised care
Care plans recorded people's needs, preferences and risks. Staff knew people's personalities and personal histories and supported their choices.
“People's preferences had been gathered and support was delivered in line with their wishes.” from the report
Suitable staffing and training
There were enough staff, recruitment checks were completed, and staff received training and supervision. Inspectors saw staff supporting people safely.
“The provider maintained a rota and ensured there were enough staff on shift at all times.” from the report
Good food and health support
People had meal choices and support with specialist diets. The home monitored weight where needed and worked with dieticians and other health professionals.
“People were supported to eat and drink enough and maintain a balanced diet.” from the report
People's involvement
People and relatives were involved in care decisions and could give feedback through meetings, reviews and surveys. The home responded to requests for more activities.
“People and their relatives were involved in making decisions about care and support.” from the report
Cleanliness and infection control
seriousParts of the building and furniture were visibly dirty. Deep cleaning, repairs and replacement of damaged furniture were needed to reduce infection and cross-contamination risks.
“There were ineffective measures in places at the home to ensure the risk of infection and cross contamination was prevented and/or minimised.” from the report
Environmental safety
seriousExposed pipework was hot to the touch and posed a burn risk. The provider said it would be covered, and later confirmed padding had been added after the inspection.
“For example, exposed pipework which was hot to the touch, and posed a burn risk to people had not yet been covered in the lounge area.” from the report
Slow follow-through on improvements
needs fixingThe provider and manager carried out audits, but did not always complete actions promptly when problems were identified.
“However, actions were not always taken in response to identified areas of improvement, in a timely way.” from the report
Mental-capacity records
needs fixingSome records about people's capacity to make decisions were not up to date. New care-record formats were being introduced during the inspection.
“We found the provider did not always have up to date care records of the assessment of people's capacity, where they lacked the capacity to make all their own decisions.” from the report
More activities wanted
minorSome people said they wanted more activities to keep them stimulated. The provider said it was expanding the programme in response.
“Some people explained they would like more things to do to stimulate them.” from the report
- 01What cleaning, repair and furniture-replacement work identified in the inspection has now been completed?
- 02How do you check that hot pipework and other environmental risks remain safe for residents?
- 03How do you make sure audit findings lead to prompt action, and can we see the current improvement plan?
- 04Are all mental-capacity assessments and best-interests decisions now up to date?
- 05What extra activities have been introduced in response to residents asking for more things to do?
This was a planned comprehensive inspection covering all five questions and both the premises and care provided; the previous Good rating was under a former provider. This explanation was written from the published report of 6 March 2019 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 Cliffdale Rest Home
3 rated inspections over 4 years: the service has held its Good rating throughout.
- April 2020Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- July 2012
Registered with the Care Quality Commission on 2 July 2012.
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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