CQC report explained · a residential care home
What the CQC found at Radcliffe Manor House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, July 2023
Radcliffe Manor House: Inspected but not rated; inspectors found the earlier warning notice had been met, but the previous Requires Improvement rating remains.
This was an unannounced, targeted inspection on 28 June 2023. One inspector checked a specific concern about personal safety and the safe environment, following a previous warning notice.
Inspectors found that risks linked to people leaving the building without being noticed were better managed. Secure coded doors, alarms on fire exits and regular observations were in place. Staff had also received face-to-face dementia training.
Some written risk instructions needed more detail, and staff said written guidance could be clearer. The registered manager dealt with some of this during the inspection.
The home was not given a new rating. Its previous overall rating remains Requires Improvement. The earlier breach of Regulation 12 was no longer in place, but the other areas and the full Safe question were not assessed.
Safer entrances and exits
Secure coded access had been fitted to three entrance and exit doors. People who had capacity were given access to the codes.
“three entrance and exit doors had secure coded access fitted to ensure people who lacked capacity to leave the building were kept safe.” from the report
Exit alarms
Alarms on some fire exits alerted staff through handheld devices if a door was opened. This reduced the risk of someone leaving without being noticed.
“Fire exits that were also potential risk for someone at risk of absconding or leaving the home undetected had alarms fitted to identify to staff on handheld devices” from the report
Regular observations
People at risk of leaving unattended were placed on observations at 15-to-30-minute intervals. This helped staff know where they were.
“they were put on observation with 15-to-30-minute intervals to ensure staff knew where the person was at all times” from the report
Dementia training
Staff had received face-to-face dementia training. Inspectors said this supported staff to manage agitation, frustration or a wish to leave.
“Staff had received face to face dementia training since our last inspection.” from the report
Written guidance was not clear enough
needs fixingSome risk instructions needed more detail, and staff said the written instructions could be clearer. The registered manager addressed this during the inspection.
“However, they felt written instructions could be clearer.” from the report
Incident records were still being moved
minorAccident and incident records were being transferred to an electronic system. Until this was complete, the planned improved oversight of themes and trends was still in progress.
“The registered manager told us they were in the process of transferring the accident and incidents to the electronic system.” from the report
- 01How are the coded doors and fire-exit alarms checked, and what happens if one fails?
- 02How are people at risk of leaving the home monitored, and how often are the 15-to-30-minute observations recorded?
- 03Have all risk assessments and written instructions now been updated with the extra detail inspectors said was needed?
- 04Has the transfer of accident and incident records to the electronic system been completed?
- 05What were the findings of the last full inspection, given that this inspection did not assess the whole Safe question or the other four questions?
This was a targeted inspection of a specific personal safety concern and the safe environment; it did not assess the whole Safe question or the other key questions, so the previous ratings carry over. This explanation was written from the published report of 15 July 2023 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, May 2023
Radcliffe Manor House is rated Requires Improvement; inspectors found risks and medicines were not always managed safely, and quality checks were not reliable.
This was an unannounced focused inspection. Inspectors visited on 15 February 2023 and 12 April 2023. They reviewed Safe and Well-led after concerns linked to an inquest response.
The home was not always safe. Risk assessments and records did not always explain how people should be protected. Medicines were not always recorded, stored or audited safely. Some people and staff also said more staff would help at busy times.
The home was clean and infection control was mostly effective. People were protected from abuse, staff recruitment was safe, and healthcare professionals were involved when people's needs changed. However, the provider's checks did not find or fix all the problems.
The overall rating changed from Good to Requires Improvement. This means some aspects of the home were not always safe or well managed, and there was limited assurance about safety.
Safeguarding
Safeguarding systems were in place. Staff knew how to report concerns, and people and relatives said they felt safe.
“People were protected from avoidable harm and staff knew how to raise concerns about poor practice.” from the report
Infection control
Inspectors found the home clean and were assured that infection risks, visitors and protective equipment were being managed.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Healthcare support
Staff recognised changes in people's needs and made timely referrals to health and social care professionals.
“This ensured people received the care they needed.” from the report
Action started
After concerns were raised, the provider began putting controls in place for a person at risk of leaving the building.
“During our second visit we identified the provider had started to implement control measures for the person at risk of leaving the building.” from the report
Risks were not controlled
seriousOne person had left the home five times without staff knowledge. There was no risk assessment, incident record or detailed staff guidance for this risk over the stated period.
“The provider failed to manage and mitigate all risks. This placed people at risk of harm.” from the report
Medicines records and storage
seriousPRN instructions were missing, allergies were not recorded on medicine charts, controlled drug records were inaccurate and temperature records had gaps. Audits had not found or properly addressed these issues.
“Medicines were not always managed in a safe way. Medicine audits failed to identify some issues and concerns.” from the report
Weak quality checks
seriousCare plans, risk assessments, incident records and audits were not always accurate or detailed enough. This meant the provider could not reliably monitor and reduce risks.
“Systems and records had not been established to assess, monitor and fully mitigate risks to the health, safety and welfare of people using the service.” from the report
Water safety checks
needs fixingWater testing records did not include temperatures for occupied bedrooms. Inspectors were not assured that the home was following health and safety guidance for Legionella or scalding risks.
“This placed people at risk of scalding. There was no evidence of any scalding incident.” from the report
Staffing pressure
needs fixingSome people and staff felt more staff were needed during busy periods. The home was using agency staff to cover shortfalls and was recruiting.
“They [staff] try their best, they are short staffed, I can go to the toilet myself, but if I do need help, I have to wait.” from the report
- 01What specific risk assessment and staff instructions are now in place for anyone who may leave the building unattended?
- 02How do you check that PRN instructions, allergies and controlled drug records are complete and accurate?
- 03How are medicine fridge and room temperatures recorded, checked and acted on when there are gaps?
- 04What changes have been made to water temperature testing and Legionella management?
- 05How are staffing levels covered during busy periods, and how do staff raise concerns or suggestions now?
This was a focused inspection of Safe and Well-led only, prompted by concerns linked to an inquest; the report does not give current ratings for the other three key questions. This explanation was written from the published report of 20 May 2023 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 Radcliffe Manor House
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- July 2023Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- May 2023Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- January 2019Goodstayed GoodSafe: GoodWell-led: Good
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 17 January 2011.
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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