This inspection took place on the 12 and 13 April 2018. The inspection was undertaken to check whether the provider had made the improvements required from our previous inspection in September 2017 and was now meeting all of the legal requirements and regulations associated with the Health and Social Care Act 2008. The inspection was also to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

Clifford House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Clifford House is a small family owned residential care home located in a residential area of Andover. The home is arranged over two floors and can accommodate up to 21 people. At the time of our inspection there were 16 people living at the home. The home supports people with a range of needs. Some people were quite independent and only needed minimal assistance, whilst others were more dependent and needed assistance with most daily living requirements including support with managing their personal care and mobility needs. Some of the people being cared for in the home were living with dementia and could at times display behaviour which might challenge others.

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

Following the last inspection, we asked the provider to complete an action plan to show what they would do, and by when, to improve the key questions, safe, effective, responsive and well led to at least good. Some of the required actions had been completed. For example, improvements had been made to ensure that people were protected from risks associated with the environment. Risks to people’s health and safety were now being more robustly assessed and plans were in place to mitigate these risks.

Improvements had been made to ensure that people’s care plans fully reflected their needs.

The provider was now undertaking all of the required checks before staff started working at the service and improvements had been made to ensure the home was clean throughout.

However, we found continuing concerns with regards to how medicines were being managed. In addition, whilst improvements had been made to the governance arrangements within the service, these were still not being fully effective at identifying areas where safety was compromised, or to ensure compliance with the Regulations.

There had been an improvement with the frequency of supervision but this needed to be embedded and sustained. Appraisals had not yet taken place for all staff.

Staff were providing people with increased opportunities for meaningful interaction, but some people felt more could still be done to offer a greater range of activities. We have also made a recommendation about developing the activities provided to people living with dementia.

Other areas remained good. There were sufficient numbers of staff deployed to meet people’s needs.

Staff had received training in safeguarding adults, had a good understanding of the signs of abuse and neglect and knew how to report any concerns.

Staff acted in accordance with the principles of the Mental Capacity Act 2005.

People told us they enjoyed the food provided and staff were well informed about their dietary requirements.

The home had continued to work effectively with a number of health care professionals to ensure that people received co-ordinated care, treatment and support.

Staff were kind and caring in their interactions with people and treated them with dignity and

This inspection took place on the 19 and 20 September 2017. The inspection was undertaken to check whether the provider had made improvements and was now meeting all of the legal requirements and regulations associated with the Health and Social Care Act 2008. The inspection was also to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

Clifford House is a small family owned residential care home located in a residential area of Andover. The home is arranged over two floors and can accommodate up to 21 people. At the time of our inspection there were 20 people living at the home. The home supports people with a range of needs. Some people were quite independent and only needed minimal assistance. Others were more dependent and needed assistance with most daily living requirements including support with managing their personal care and mobility needs. Some of the people being cared for in the home were living with dementia and could at times display behaviour which challenged others.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. The registered manager was also the registered provider. For the last 12 months, the registered manager had not been providing day to day management of the service but had instead appointed a manager to perform this role. The manager had been appointed in October 2016, but had not yet submitted an application to the Care Quality Commission to become the registered manager.

People had not always been protected from risks associated with the environment.

The provider had not taken proper steps to ensure that all of the required checks had been completed before staff started working at the service.

Improvements to the cleanliness of the home were needed.

Medicines were not always managed safely. We could not be confident that people were receiving their medicines as prescribed.

The provider had not adequately assessed risks to people’s health and safety and done all that was reasonably practicable to mitigate such risks.

Changes to people’s needs had not always been effectively communicated within the staff team.

Improvements were needed to the governance arrangements within the service. The provider and manager did not operate a robust programme of audit and checks to ensure the safety and quality of the service was being maintained.

Records were not available which demonstrated that staff had received an appropriate induction, supervision and an appraisal.

More needed to be done to ensure that staff provided people with increased opportunities for meaningful interaction.

There were sufficient numbers of staff deployed to meet people’s needs.

Staff had received training in safeguarding adults, had a good understanding of the signs of abuse and neglect and knew how to report any concerns.

Staff acted in accordance with the principles of the Mental Capacity Act 2005. Where people's liberty or freedoms were at risk of being restricted, the proper authorisations were in place or had been applied for.

People told us they enjoyed the food provided and staff were informed about whether people were nutritionally at risk and measures put in place to address any risks.

The home worked effectively with a number of health care professionals to ensure that people received co-ordinated care, treatment and support.

Staff were kind and caring in their interactions with people and treated them with dignity and respect?

People and their relatives were involved in making decisions and planning their care.

People knew how to make a complaint and information about the complaints procedure was included in the service u

This inspection was unannounced and took place on the 13, 14 and 21 July 2016.

Clifford House is a care home which provides residential care for up to 20 older people living with a range of medical conditions including diabetes and those living with epilepsy and Dementia.

The care home comprises of two floors situated within its own secure grounds and garden in a residential area on the outskirts of Andover town centre. The home has 20 rooms, a communal lounge and dining room with television, bathrooms and a small sitting area in the back garden with furniture for people, relatives and visitors to enjoy. Meals were served at people’s choice in their rooms, lounge or dining room. At the time of the inspection 16 people were living at the home.

Clifford House has a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. 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 service is run. The registered manager was not present at the home during the inspection but was available to be spoken and communicated with during this time. Throughout this report care staff will be referred to as ‘staff’.

The provider did not ensure that accurate records were in place to ensure there were sufficient staff deployed to ensure that people’s individual needs were met in a timely fashion. The provider had not ensured that regular reviews of people’s dependency needs were carried out to identify the correct number of staff required to meet people’s needs.

The home did not always ensure that people living with dementia had appropriate opportunities to participate in meaningful activities to ensure they led a full and active life. We have made a recommendation that more activities for those living with dementia are made available to people.

Contingency plans were not in place prior to the inspection to ensure the safe delivery of people’s care in the event of adverse situations such as a fire. This was brought to the registered manager’s attention during the inspection and a detailed plan was then created. Fire drills were documented, understood by staff and practiced to ensure people were kept safe. However staff did not know what practices were in place to ensure people received a continuity of care in the event of an on-going adverse situation such as fire or flood which meant the home was inhabitable.

The provider had not always ensured that actions resulting from quality control audits had been completed in order to improve the quality of the service provided. The registered manager had not always taken steps to address these and ensured that appropriate actions were taken.

Care plans and associated paperwork were not always accurately updated when people’s needs changes so healthcare professionals would be able to provide the care people needed when away from the home.

Relatives and people told us they felt that the registered manager was not always a visible presence in the home. Staff told us they felt supported by their colleagues and senior staff however they did not always feel this support from the registered manager.

Relatives of people using the service told us they felt their family members were kept safe. Staff understood and followed guidance to enable them to recognise and address any safeguarding concerns about people. People’s safety was promoted because risks that may cause them harm had been identified and guidance provided to manage these appropriately. People were assisted by staff who encouraged them to remain independent. Appropriate risk assessments were in place to keep people safe.

Recruitment procedures were completed to ensure people were protected from the employment of unsuitable staff.

People were protected from the unsafe administration of medicines. Se

During an inspection in June 2014 we found the provider had not met the required standard with respect to the maintenance of an accurate record of the care and treatment each person living at Clifford received. This was because we found some care records had not been stored securely. We also found that some care plans contained conflicting or out of date information and that records of the care people received on a daily basis had not always been completed. The provider sent us an action plan telling us what action they would take to ensure they met the required standard. The purpose of this inspection was to check whether the provider had made the necessary improvements. We therefore looked at the records maintained by the service to answer the question is the service safe?

On the day of the inspection there were 20 people living at the home.

This is a summary of what we found –

Is the service safe?

The provider had taken action to help ensure that people who use the service were safe by the maintenance of an accurate record of the care and treatment they received. People’s care records were kept securely, but readily available to staff when required.

Overall, care plans and other records were accurate and fit for purpose. Charts used to monitor aspects of people’s personal care tasks had mostly been fully completed. Arrangements were now in place to document weekly blood sugar checks and people’s fluid intake where these were required. We did note that the forms used for recording this information could be improved to help ensure that staff had sufficient guidance to enable them to effectively respond to fluctuations in blood sugar readings.

The application of topical medicines was being recorded on a topical medicines administration record (TMAR). Topical medicines are creams or lotions which are applied to the body to treat skin conditions. We did see a small number of examples where the application of a person’s creams had still only been recorded in their daily records. Therefore the use of a TMAR needs to be embedded in practice and sustained to ensure that these are an accurate record of the topical medicines people receive.

Clifford House is a residential care home located in Andover in Hampshire. It is registered to provide accommodation and personal care for up to 21 people some of whom are living with dementia. At the time of our visit there were 19 people living at the home. Clifford house is an older style house that has been converted into residential care accommodation arranged over two floors. The home has a communal lounge and dining area, a kitchen and adapted bathing facilities. A walk in shower is currently being installed. There is access from the communal lounge to a small outdoor patio area.

The home has a registered manager who is also the registered provider of the service. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service and shares the legal responsibility of meeting the requirements of the law alongside the provider.

During the inspection we spoke with six people who use the service. Where people were unable to speak with us due to their complex needs, we used other methods to help us understand their experiences including observation of their support. We spoke with a number of staff including the registered manager, and three care workers. We reviewed 10 people’s care and support plans and other relevant records.

We had previously assessed that Clifford House Residential Care Home had not been meeting six of the essential standards. This inspection, reviewed whether they had taken action and made the required improvements to comply with these standards. In addition, we also reviewed whether the service was meeting the essential standards in relation to records and the management of medicines.

We gathered evidence against the outcomes we inspected to help us answer our five key questions.

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

Below is a summary of what we found. If you want to see the evidence supporting our summary please read our full report.

Is the service safe?

People living at Clifford House told us that they felt safe. Safeguarding procedures were in place and staff understood how to safeguard the people they supported.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Whilst no-one living at the service was currently subject to a DoLS, we found that the manager understood when an application should be made and how to submit one and was aware of a recent Supreme Court Judgement which widened and clarified the definition of a deprivation of liberty.

We found that some people's care records contained incomplete monitoring charts which meant that accurate monitoring of their needs would be difficult. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the maintenance of accurate and appropriate records to ensure that people are fully protected against the risks of unsafe or inappropriate care.

Is the service effective?

Before people received care, they were asked for their consent and care staff acted in accordance with their wishes. The manager was knowledgeable about the Mental Capacity Act (MCA) 2005 and was able to demonstrate an understanding of assessing people's capacity to make decisions. Care staff displayed knowledge of the key principles of the MCA and we saw records which showed that all staff had completed training in the MCA.

People’s care plans included information about the care and support they needed. Staff we spoke with were informed about people’s needs and were able to tell us about the care they provided.

The provider had made arrangements to ensure that a programme of repair and on-going improvement was maintained within the service, which ensured that people were protected against the risks of unsafe premises and were cared for within a comfortable and pleasant environment.

The provider had put in place arrangements to provide staff with supervision and appraisals. Whilst we found that improvements had been made to the frequency of supervision, and staff told us that they felt well supported, these improvements will need to be embedded in practice and sustained to ensure that they were a fully effective tool in supporting the development of staff.

Is the service caring?

People we spoke with were positive about their care and the support they received from staff. One person said, “The staff are very kind, they always go out of their way, no-one could complain”. Another person said, “You come here, you come home, you belong”. A third person said, “They [staff] are kind and caring”.

People’s preferences, likes and dislikes had been recorded and we saw that support was provided in accordance with people’s wishes.

Is the service responsive?

The service had measures in place to review people’s needs on a regular basis. We saw that action was taken in response to any changes in people’s needs. For example, we saw that one person was referred to their GP when they developed signs or symptoms of a urine infection. Another person had been referred for a continence assessment and a GP had been consulted about a third person’s skin complaint. This meant that the service worked effectively with other providers to ensure that people received co-ordinated care, treatment and support.

Systems were in place to ensure that the service learnt from incidents and accidents, comments and complaints.

Is the service well led?

There were arrangements in place to ensure that people who use the service, their representatives and staff were asked their views about the care the service provided. We saw that where the need for improvement was identified, the service was taking action to address this.

The service had taken action to ensure that it had quality assurance systems in place to assess the quality of the service and identify where improvements could be made. However some of these needed to be further embedded to ensure that they provided an effective system for monitoring the quality and safety of the service people received. For example, some of the care records at the home were not clear or incomplete. These issues had not been identified through the audit process.

When we visited there were 18 people living at Clifford House. We spoke with the provider, two care workers and four people who used the service. We reviewed a range of documents relating to the management of the home and observed care.

During our inspection on 27 November 2013, we found that the service had not protected people against the risks associated with unsafe premises. As a result of that inspection, we served the provider with a warning notice in relation to the safety and suitability of the premises with a requirement that they become compliant by 31 January 2013. On the 25 February 2014 we carried out a follow-up inspection to check whether the home had become compliant.

Prior to the inspection on 25 February 2014, we had become aware of concerns that staffing levels within the home might at times be impacting upon the ability of staff to provide person centred care and enable people to express choice about how and when their needs were met. Therefore this inspection also looked at whether the provider had ensured that there were adequate numbers of suitably qualified staff on duty at all times.

We found that the home had made some improvements to the safety of the premises since we last inspected. Work had been completed to secure the windows in order to ensure that the home maintained a safe environment for vulnerable people. Equipment had been installed to assist in maintaining safe water temperatures to prevent the risk of scalding to people who used the service. However, work to ensure effective legionella control and monitoring was in progress but had not been fully completed.

People told us that there were sufficient number of care workers to meet their needs and that staff responded promptly to call bells or requests for assistance. We found that the provider had arrangements in place to respond to changing circumstances in the service, for example to cover staff sickness or absence.

When we visited the service there were 19 people living at the home. We spoke with three staff, the manager and six people who use the service. We viewed the care plans for seven people. People we spoke to were positive about their care and treatment and the skills of the staff. People told us, ‘staff are kind and come when called’. Another said, ‘thank goodness I have found a place I feel at home in’. People told us they felt treated with respect and that staff provided care in a manner that promoted their dignity.

However, there were not adequate arrangements in place to make sure staff acted in accordance with legal requirements where people who used the service did not have capacity to consent to their care and treatment. Adequate arrangements were not in place for ensuring that the service took account of the requirements of the Mental Capacity Act 2005 Deprivation of Liberty Safeguards. We observed that the care plans did not always provide sufficient detail about key risks to a person’s health and welfare and how these should be managed.

We found that people might not always be protected from abuse as staff did not have up to date safeguarding training. Key risks associated with the premises had not been identified including inadequate water safety checks and the risk of falls from unrestricted windows on the upper floor. We also found that the quality monitoring arrangements were not sufficiently robust.

We chatted with ten people who were using the service on the day of our inspection. They all confirmed to us that they were well and that staff treated them well. Some people were less able to communicate their experiences to us and we sat in the lounge to observe how they were feeling. Everyone appeared to be relaxed and staff were on hand to offer drinks and support. During the six hour period that we were on site some people received minimal social interaction. Three people told us that they were sometimes bored and that they would appreciate the opportunity to go on more outings and to join in with more activities.

We found that the needs and risks of people using the service had been assessed. Care plans were in place for everyone receiving personal care and these had been reviewed in line with the provider's policy. Staff had had access to good training and were competent in their caring role. However there were some gaps in terms of continual supervision and professional development. Safeguarding procedures were in place and staff knew how to report suspected abuse. There was scope to improve the risk assessment process around malnutrition and skin integrity in order to ensure that preventative measures were used to maximum effect.

People said that staff listened to their opinions and confirmed that their privacy was respected. People generally felt well cared for. They said that the home was always clean and tidy.