CQC report explained · a residential care home
What the CQC found at Clitheroe Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, July 2022
Rated Requires Improvement, with an Inadequate well-led rating; inspectors found serious problems with safety, records and management.
This was an unannounced focused inspection. Inspectors visited on 27 and 28 April 2022 and reviewed information, records, medicines, staff files and the way the home was managed. They spoke with people living there, a relative, staff and a healthcare professional.
The home was not always safe or effective. Medicines records were inaccurate, fire risks were not properly managed, infection control was inconsistent and safeguarding procedures were not always followed. Care plans and risk assessments were missing or incomplete. Some staff training and moving and handling practices also needed improvement.
The biggest concern was management and oversight. Records, audits and incident reporting were not reliable, and the home did not have a registered manager in post. The provider was given a warning notice for poor governance and must send an action plan. CQC said it would continue to monitor the home.
The overall rating fell from Good at the previous inspection, published in December 2020, to Requires Improvement. The Safe and Effective ratings were Requires Improvement, while Well-led was Inadequate. Caring and Responsive were not inspected in this visit, so their previous ratings were used in calculating the overall rating.
People felt safe
People living at the home told inspectors they felt safe. A relative also said they believed their relative was safe.
“People told us they felt safe at the home” from the report
Adequate staffing
Inspectors found staffing levels were adequate, although recruitment paperwork still needed improvement.
“Staffing levels were adequate, however recruitment processes required improvement.” from the report
Positive food feedback
People and relatives spoke positively about the food provided.
“People and their relatives spoke positively about the food being provided.” from the report
Staff knew how to report poor practice
Staff knew how to use the whistleblowing process to report poor practice.
“A whistleblowing policy was in place and staff knew how to report poor practice.” from the report
Medicines were not consistently safe
seriousMedicines records and stock checks did not always match. Medicines and equipment were also found that belonged to people who no longer lived at the home.
“Medication records and stock checks did not always correspond, meaning it was difficult to ensure people were receiving medication, in line with the prescriber's recommendations.” from the report
Fire and other safety risks
seriousInspectors found concerns about fire safety and referred the home to the local fire prevention team. Other environmental risks were not always properly assessed or managed.
“Following the inspection, we referred the home to the local fire prevention team.” from the report
Care plans did not always meet needs
seriousSome people did not have the required assessments, health-related risk assessments or care plans. A recommended diet had not been put in place several weeks after a dietician's advice.
“One person had been referred to a dietician who had recommended a specific diet to mitigate the risk of further weight loss.” from the report
Consent processes were incomplete
seriousNecessary liberty safeguard referrals, capacity assessments and best-interest decisions were not always in place. Not all staff had completed the relevant training.
“Necessary DoLS referrals were not always being made.” from the report
Poor oversight and records
seriousImportant records were incomplete, out of date or inaccurate, and audits did not always identify problems. Three incidents were not reported to CQC and the local safeguarding team when they should have been.
“Some of the audits that were carried out did not always identify the issues we found at this inspection and were therefore not robust enough.” from the report
- 01What has been done to make medicines records, stock checks, storage and pain management fully accurate and safe?
- 02What did the local fire prevention team find, and have all fire safety concerns now been fixed?
- 03Which person is currently responsible for managing the home, and when will there be a registered manager in post?
- 04How have care plans, risk assessments, capacity assessments and best-interest decisions been reviewed since the inspection?
- 05What evidence can you show that the warning notice about governance has been addressed and that audits now identify problems?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were used to calculate the overall rating. This explanation was written from the published report of 7 July 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, January 2021
Inspected but not rated; inspectors were assured that infection control and COVID-19 measures were keeping people safe.
This was an unannounced, targeted inspection on 13 January 2021. It followed a COVID-19 outbreak and concerns about infection prevention and control. Inspectors checked records, spoke with managers and staff, and observed practices in the home.
Inspectors found enough PPE, hand sanitiser and staffing arrangements to reduce infection risks. Staff were using PPE safely and people and staff were being tested. The home had infection control policies, outbreak plans and regular monitoring.
The report also records some issues. There were errors in the staffing rota and an unpleasant odour on the first floor, but managers addressed these during the inspection. Visiting was restricted because of national lockdown and the outbreak.
The home was inspected but not rated. This means the report gives an assurance about infection prevention and control, but it is not a full overall rating of the home.
PPE and hand hygiene
There were enough stocks of PPE and hand sanitiser was available throughout the home. Staff had been trained and were observed using PPE correctly.
“We were assured that the provider was using PPE effectively and safely.” from the report
COVID-19 testing and response
Inspectors found that testing was available and that appropriate action was taken when people or staff had symptoms or positive results.
“We were assured that the provider was accessing testing for people using the service and staff and appropriate action was being taken in response to COVID symptoms and positive test results.” from the report
Outbreak planning
The home had an up-to-date infection control policy, a COVID-19 response plan and regular monitoring. Inspectors were assured that the outbreak was being managed safely.
“We were assured that the provider was making sure the current infection outbreak was effectively managed and ensuring future outbreaks would be managed safely and effectively.” from the report
Staffing rota errors
needs fixingInspectors found some errors in recording staff attendance and absence. The regional manager addressed this immediately.
“We discussed maintaining an accurate staffing rota as we noted some errors in the recording of attendance and absence” from the report
Unpleasant odour
minorAn unpleasant odour was noticed in an area on the first floor. The manager addressed it and increased cleaning.
“There was a good standard of cleanliness in all areas seen. However, we noted an unpleasant odour in an area on the first floor” from the report
- 01What checks are now in place to make sure the staffing rota accurately records attendance and absence?
- 02What caused the unpleasant odour on the first floor, and how do you check that it has not returned?
- 03Was the planned signage about putting on and removing PPE installed, and how is staff practice checked now?
- 04What are the current visiting arrangements following the COVID-19 outbreak and national lockdown?
- 05Are new admissions currently being accepted, and what infection control steps apply?
This was an unannounced, targeted inspection of infection prevention and control during a COVID-19 outbreak; it did not assess the other four CQC questions or give an overall rating. This explanation was written from the published report of 27 January 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 Clitheroe Care Home
3 rated inspections over 2 years: the service has slipped, from Good to Requires improvement.
- July 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Inadequate
- January 2021Inspected but not ratedSafe: Inspected but not rated
- December 2020Goodstayed GoodSafe: GoodWell-led: Good
- April 2020GoodSafe: GoodEffective: GoodWell-led: Good
- February 2019
Registered with the Care Quality Commission on 22 February 2019.
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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Most charge £980 to £1,260 a week. 78 can care for a couple. 11 years' experience on average.
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