Clair Francis Retirement Home

Clair Francis Retirement Home is a two storey adapted building and provides accommodation and personal care for up to 28 older people, some of whom are living with dementia. At the time of the inspection, 19 people were living in the home.

People’s experience of using this service and what we found

Risks to people including those for falls, infection prevention and control, choking, skin integrity, fire safety and malnutrition had been identified. Systems and processes in place helped ensure risks were mitigated or removed.

Staff had training on how to recognise and report abuse and had the skills to protect people from poor care and abuse, or the risk of this happening. The service worked with other agencies to do so. The service had enough appropriately skilled staff to meet people's needs and keep them safe.

People were supported to make decisions that meant risks could be taken, managed in a safe way and were in people's best interests; the policies and systems in the service supported this practice.

Medicines were administered and managed safely. Incidents and accidents were reviewed, and learning was shared across the staff team. Staff had enough personal protective equipment, used this effectively and disposed of it safely. Visitors were supported to visit the service safely.

Oversight, governance and the provider's monitoring systems were effective in identifying and driving improvements. There was an open and honest staff team culture. The reporting of incidents meant changes made helped reduce the risk of recurrences. The registered manager supported staff in a positive manner, was approachable and had an open door policy where staff were listened to and actions taken were effective.

People, relatives, staff and others involved in people's care had a say in how the service was run, and compliments were used to help identify what the service did well. The registered manager and staff team worked well with outside agencies to ensure people received the care and support they needed. Staff felt supported in their roles.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was Requires improvement (report published 25 March 2022) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

Why we inspected

This focused inspection of the safe and well-led key questions was carried out to follow up on action we told the provider to take at the last inspection. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Clair Francis Retirement Home on our website at www.cqc.org.uk

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Clair Francis Retirement Home provides accommodation and personal care for up to 28 older people, some of whom are living with dementia. At the time of the inspection, 20 people were living in the home.

People’s experience of using this service and what we found

Risks to people were not always identified, managed or reviewed to ensure people were safe and protected from harm. People were not always protected from the risk of cross contamination of infection due to some poor infection prevention and control practices. Incidents and accidents were not always reported in a timely way to the registered manager.

Analysis of incidents to identify patterns to learn lessons and prevent reoccurrence had not always taken place, thus placing people at further risk. The provider, registered manager and provider’s consultant responded positively to our feedback and took action to mitigate the risks to people.

Oversight of the quality of the service provided and audits carried out had not always been effective in identifying areas for improvement and ensuring they were completed in a timely manner. Processes to monitor people's standards of care were not clear and we found gaps in recording and or monitoring that had not been addressed. This increased the risk that people would not receive the care they required.

People, their relatives and staff had been asked for their feedback on the service being delivered. The staff worked well with outside agencies to ensure people received the care and support they needed. Staff felt supported in their roles. Relatives of people living in the home told us that the registered manager was approachable and kept them up to date with how their family member was.

New staff had been recruited safely to ensure the right people were employed. There were sufficient number of staff working in the home to meet people’s needs in a timely manner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was good (report published 09 October 2019.) The rating has changed to requires improvement.

Why we inspected

As part of CQC’s response to care homes with outbreaks of COVID-19, we are conducting reviews to ensure that the Infection Prevention and Control (IPC) practice is safe and that services are compliant with IPC measures. This was originally a targeted inspection looking at the IPC practices the provider has in place. Due to IPC concerns identified during the inspection we widened the scope of the inspection to become a focused inspection including the Safe and Well-led key questions. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.

We have found evidence that the provider needs to make improvements. Please see the Safe and Well-led sections of this full report. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Clair Francis Retirement Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to reducing risks to people’s safety and quality assurance of the service being provided at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice:

The provider had purchased a computer tablet to allow people and their friends and family to keep in touch virtually.

Clair Francis Retirement Home is a residential care home providing personal care for up to 28 older people some of whom are living with dementia. At the time of this inspection there were 19 people living at the service. Accommodation is provided in one adapted building, over two floors.

People’s experience of using this service and what we found

People were well cared for by staff who loved their jobs. People using were relaxed with staff and the way staff interacted with people had a positive effect on their well-being. People were treated with kindness, respect and compassion and their privacy, dignity and independence were promoted.

Systems and process were in place at the service which kept people safe in all areas of their care including the administration of medicines.

Care plans were in place which supported staff to deliver personalised care. People were supported to maintain their health and access healthcare support. Staff worked in partnership with other agencies to ensure people received the right support.

People’s feedback was consistently positive about the care they received. People particularly liked the service because of the caring staff. One person told us, “It’s all very nice, staff, surroundings, everything. I can get up when I like and go to bed when I like.”

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Enough staff were available on each shift to support people and robust recruitment checks were carried out before staff started working at the service. Staff received induction, training and supervision to ensure that they had the right skills and abilities to support people.

People were supported to eat and drink enough to maintain a balanced diet.

Systems were in place to monitor the service, which ensured that people's risks were mitigated, and lessons were learnt when things went wrong. There was an open culture within the service, where people and staff could approach the registered manager who acted on concerns raised to make improvements to people's care.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 6 April 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

This comprehensive inspection took place on 2 March 2017 and was unannounced.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the home. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the home is run.

Systems were in place to assess and manage risks to people using the service. Staff understood the risks for people and their responsibilities within the home. Information about emergencies was available for staff.

People’s capacity to make decisions for themselves had been assessed. Staff were trained and understood the principles of the MCA and DoLS and were able to describe how people were supported to make decisions if they lacked capacity. We saw that appropriate DoLS authorisations were in place to lawfully deprive people of their liberty. Authorisations in place were for people’s own safety because they were unable to make decisions on where they should live safely.

People were kept safe because there was a sufficient number of staff on duty to meet people’s needs. The provider had a recruitment process in place and staff were only employed within the service after all essential safety checks had been satisfactorily completed. Staff received an induction when they started work and further training was available for all staff which provided them with the skills they needed to meet people’s needs.

Staff knew how to support and meet people’s needs. People were involved in how their care and support was provided. People had access to health care professionals when they needed them. Staff treated people with care and respect and made sure that their privacy and dignity was respected all the time.

People and staff were able to provide feedback and information so that the provider could monitor and improve the quality of the service. The registered manager was open and available for people, their relatives, staff and professionals to discuss concerns or make comments to improve the service.

During this inspection on 31 October 2013 we found that the provider had now undertaken a documented dependency and risk based assessment on each person's individual care and support needs. The provider told us that this analysis helped determine the number of staff needed to deliver safe and effective care and support to people using the service.

People we spoke with during our inspection raised no concerns around the current level of staffing within the home. One person went on to tell us that, "Staff are available to help."

We found that there were no effective systems in place to make certain that staff levels ensured the safety and well-being of people who lived at the home. The provider was unable to evidence a risk based assessment which demonstrated to us that safe staffing levels were determined from both service user's numbers and their individual needs. A person who used the service told us that, "We sometimes have to wait for help when staff are busy." Another person told us that, "I do have to often wait for help because staff are busy."

Adequate staff training was in place to make sure that people who used the service received safe support and care from suitable, skilled, and knowledgeable staff.

The name of a registered manager appears in this report who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time.

We saw documented evidence where people did not have capacity to consent to safe care and treatment. This meant that the provider acted in accordance with legal requirements.

People's standard of care and welfare was maintained. Staff had access to detailed care records to ensure that they provided care and support to people.

When reviewing Medication Administration Records we did not see evidence of accurate documentation to ensure that people were protected against the misuse of medication.

There were effective staffing levels in place to ensure the safety and well-being of people who lived at the home.

We saw an effective quality assurance system was in place as the provider generated action plans using the results from surveys and audit to improve the quality of the service delivered.

The name of a registered manager appears in this report who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time.

The professionals we spoke with raised no concerns over the care and support people received within the home. One told us that the people they placed there seemed, "Settled and happy". This was because people received safe and appropriate care.

Care records were maintained to ensure that people received safe and appropriate care in a consistent way. A relative told us that they were, "Confident to raise a concern with management or staff". They went on to say that staff would "listen to it (a concern) and it would be taken seriously".

People were protected from the risk of infection spreading as there were effective systems in place to reduce the risk.

Effective staff recruitment were in place to ensure that people who used the service received safe and appropriate care from suitable staff.

There was an effective system in place for people to make a complaint.