CQC report explained · a residential care home
What the CQC found at Redclyffe House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People were generally protected from abuse and avoidable harm, and staff understood their risks. However, medicine records, some fire safety checks and some recruitment records were not consistently complete.
- Effective?
- Good
- This key question was not inspected during this focused inspection. Its rating was carried over from the previous inspection.
- Caring?
- Good
- This key question was not inspected during this focused inspection. Its rating was carried over from the previous inspection.
- Responsive?
- Good
- Care plans described people's histories, preferences, communication needs and desired outcomes. However, people sometimes had limited activities and outings because staff could not always support them.
- Well-led?
- Requires improvement
- The provider's quality systems did not consistently identify or resolve problems in medicines, premises, incidents, recruitment and care records. Staff also reported feeling unsettled by management changes and a lack of senior support.
What inspectors found, July 2023
Requires Improvement; inspectors found kind, personalised care, but medicines records, staffing for activities and management oversight needed improvement.
This was an unannounced focused inspection on 23 and 27 March 2023. Inspectors reviewed medicines, risks, records, premises, recruitment and quality checks. They also spoke with staff, relatives and professionals, and observed care.
The home was rated Requires Improvement overall. Safe and Well-led were both Requires Improvement. Responsive remained Good. Inspectors found people were generally treated kindly, supported to make choices and given personalised care, but some records and safety checks were incomplete.
The inspection found a breach of Regulation 17 on good governance. The provider had not checked and improved the service effectively enough, including medicine, recruitment, care and management records. CQC asked for an action plan and said it would monitor progress with the provider and local authority.
Personalised support
Care plans included people's histories, preferences, abilities and desired outcomes. Staff adapted communication and support to individual needs.
“People's care records focused on people's quality of life outcomes, and these were monitored and adapted as people went through their life.” from the report
Kind communication
Inspectors saw staff speaking respectfully and patiently. Staff gave people time to respond and supported communication in a way that suited them.
“We observed how staff communicated with people. They were respectful, kind and gave people time to respond.” from the report
Safeguarding
Staff understood how to recognise and report abuse. The home worked with outside professionals when safeguarding concerns arose.
“Staff had training on how to recognise and report abuse and they knew how to apply it.” from the report
Positive relationships
Relatives generally said people were safe and well cared for. Inspectors found that staff knew people well and supported their choices.
“People and the staff team had good relationships with each other.” from the report
Infection control and cleanliness
Inspectors were assured that infection risks were being managed, including the use of protective equipment and the handling of possible outbreaks.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Medicine records
seriousMedicine administration records had gaps and did not always explain why as-required medicines were given. Some instructions did not clearly say when to give one or two tablets or when to seek medical help.
“The registered person did not ensure records for management of medicine were fully maintained.” from the report
Management checks
seriousThe provider's audits did not consistently identify or resolve problems with medicines, premises, incidents, recruitment and care records. This was a breach because people were placed at risk of harm.
“The registered person did not operate an effective system to enable them to assess, monitor and improve the quality and safety of the service provided.” from the report
Staffing and activities
needs fixingStaff and relatives said staffing was usually enough for basic care, but not always enough for activities or outings. People also experienced long periods with little interaction or stimulation during the inspection.
“However, we observed on the first day there were long periods of time where people sat with very little interactions or activities to keep them stimulated and avoid social isolation.” from the report
Incomplete care and safety records
needs fixingSome care records did not clearly explain how often a person needed repositioning. Fire door checks had also not always been completed consistently.
“People's care and associated records were not consistently reviewed and did not always demonstrate people's needs were noted.” from the report
Management stability
needs fixingThere was no registered manager at the inspection. A recently appointed manager had applied to register but later resigned, and some staff said they felt unsettled and unsupported.
“Staff were concerned about the changes of management and felt unsupported by the provider.” from the report
- 01What has been done to make sure medicine administration records are complete and that as-required medicine instructions are clear?
- 02How many staff are normally on each shift, and how will you make sure people can go out and take part in activities?
- 03What checks now make sure care records clearly describe support such as repositioning?
- 04How are fire safety checks and other premises checks recorded and followed up?
- 05Who is currently responsible for managing the home, and how are staff being supported during management changes?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their ratings were carried over from the previous inspection. This explanation was written from the published report of 20 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, February 2021
Inspected but not rated; inspectors were assured that infection control measures were in place during the COVID-19 pandemic.
This was a targeted, announced inspection on 22 January 2021. It looked only at infection prevention and control as part of the CQC's response to the coronavirus pandemic.
Inspectors were assured that the home was using protective equipment safely, following social distancing and shielding guidance, managing testing, and keeping the home clean. They also found an up-to-date infection control policy and plans for managing outbreaks.
The home had temporarily stopped non-essential visits after a staff member tested positive for COVID-19. The manager had consulted people and families and planned to review this restriction 10 days after the inspection. The service was inspected but not rated, so this report does not give an overall quality rating.
Infection control
The home had measures covering visitors, social distancing, PPE, testing, cleaning and outbreak management.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Clean environment
The home was clean and tidy, with cleaning recorded and frequently touched surfaces disinfected regularly.
“The home was clean and tidy and had designated cleaning staff.” from the report
Communication with families
Staff kept in regular contact with families and had effective relationships with other professionals.
“The registered manager and staff communicated regularly with family of people living in the home.” from the report
Support for wellbeing
Staff provided activities in the home and spent time with people to help reduce isolation during the pandemic.
“Staff had worked hard to support people's wellbeing during the pandemic by providing in-house activities” from the report
Inspectors raised no specific concerns in this report.
- 01What happened when the planned review of non-essential visiting restrictions took place?
- 02What visiting arrangements are now in place, and what happens if there is another positive COVID-19 result?
- 03How are people supported to stay in contact with family when visits are restricted?
- 04How often are PPE supplies, cleaning records and infection control procedures checked?
- 05What activities and support are currently available to prevent people feeling isolated?
This was a targeted inspection of infection prevention and control only; the service was inspected but not rated and other areas of care were not assessed. This explanation was written from the published report of 3 February 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 Redclyffe House
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- July 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- April 2019Goodstayed GoodSafe: GoodResponsive: GoodWell-led: Good
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2014
Report published without a new overall rating.
- July 2013
Registered with the Care Quality Commission on 21 July 2013.
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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