Redclyffe House

Updated 20 July 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by three inspectors.

Service and service type

Redclyffe House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Redclyffe House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. However, a new manager had been in post for 4 months and had submitted an application to register. We will refer to them as ‘the home manager’ throughout the report. The home manager supported us on the first day of inspection along with the operations director and one of the directors. On the second day, the deputy manager, operations director and one of the directors continued supporting us with our inspection. After the inspection we were informed that the home manager had resigned.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We reviewed the last report, recent information received, and notifications sent to us. A notification is information about important events which the service is required to tell us about by law. We sought feedback from the local authority and professionals who work with the service. We used all this information to plan our inspection.

During the inspection

We spoke to the home manager, the deputy manager, operations director and one of the directors. We observed interactions between staff and people, and we spoke with one person. We reviewed a range of records relating to the management of the service, for example, records of medicines management, risk assessments, accidents and incidents, quality assurance systems, and maintenance records. We looked at 5 people's care and support plans and associated records. We looked at 5 staff files in relation to recruitment. After the inspection we spoke with 6 relatives of the people who use the service, and we received feedback from 8 staff. We continued to seek clarification from the provider to validate evidence found. We contacted 10 professionals who work with the service for further feedback.

Updated 20 July 2023

About the service

Redclyffe House is a residential home providing accommodation for people who require nursing or personal care. Redclyffe House does not provide nursing care. The service is provided over two floors with people having their own rooms with en-suites. The service provides support to people living with dementia, people with learning disabilities or autistic spectrum disorder, older people and younger adults. The service can support up to 12 and was fully occupied on the day of our inspection.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support:

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 provider needed to ensure safe recruitment procedures and better records for checks, so people were supported by safely recruited staff.

Staff supported people with their medicines in a way that promoted their independence. However, medicine management records needed improvement.

People’s care and support was provided in a safe, well-furnished environment that met their sensory and physical needs.

Staff supported people to take part in some activities. However, further improvements were needed to ensure people could pursue their interests and achieve their aspirations and goals.

People had a choice about their living environment and were able to personalise their rooms. Staff focused on people’s strengths and promoted what they could do, so people had a fulfilling and meaningful life.

Staff enabled people to access specialist health and social care support. Staff supported people to play an active role in maintaining their own health and well-being.

Staff supported people to make their own decisions following best practice in decision-making. Staff communicated with people in ways that met their needs.

Right Care:

Staff had the right knowledge to encourage and enable people to take positive risks. People received kind and compassionate care. Staff understood and responded to people’s individual needs.

Staff understood how to protect people from poor care and abuse. The service worked with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

Staff supported people consistently and understood their individual communication needs. Staff spoke to people patiently, giving them time to respond and express their wishes.

People received care and treatment that reflected their assessed needs, and this promoted their well-being and enjoyment of life.

Right Culture:

The provider did not always follow their quality assurance policy effectively to assess, monitor and mitigate any risks relating to the health, safety and welfare of people using services, the service and others.

The provider did not always maintain accurate and complete records relating to people’s care and service management.

The provider did not always ensure records demonstrated they fulfilled the requirements of duty of candour.

We found the provider notified CQC of reportable events as required. The service work together with people and those important to them to help improve the service.

Staff knew and understood people well and were responsive, supporting their aspirations to live a quality life of their choosing. People and those important to them were involved in planning their care. Staff valued and acted upon people’s views.

Staff turnover was low, which meant people received consistent care from staff who knew them well.

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 5 April 2019).

Why we inspected

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We received concerns in relation to the management of medicines, people’s care and support needs, premises, activities, management of the service and staff. As a result, we undertook a focused inspection to review the key questions of safe, responsive and well-led only. 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 good to requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report. 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 Redclyffe House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified a breach in relation to good governance and keeping accurate and complete records for medicine, staff recruitment and service management. We have made recommendation about keeping accurate records for duty of candour requirements 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.