Radcliffe Manor House

Updated 15 July 2023

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

This was a targeted inspection to check on a concern we had about personal safety and the safe environment of the service.

Inspection team

This inspection was carried out by 1 inspector.

Service and service type

Radcliffe Manor is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. 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 a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with the registered manager and 2 members of staff. We reviewed the safety of the environment and reviewed relevant processes and documents relating to the safety for people and the environment of the service.

Updated 15 July 2023

Radcliffe Manor House is a 'care home' for 26 older people. The building has 2 floors with a shaft lift and stair lift to access the top floor. There are extensive gardens to the front and rear of the property with accessible pathways. At the time of our inspection there were 21 people using the service.

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

Risks were not always assessed, monitored and mitigated for all the people living in the home.

Medicines were not always managed in a safe way. Medicine audits failed to identify some issues and concerns.

The home was clean, and infections were managed well, however there were some concerns regarding how the building was maintained.

Staff were recruited safely and in line with the providers policy and procedures, however some people and staff felt more staff would help cover busy times.

People were protected from avoidable harm and staff knew how to raise concerns about poor practice. Referrals were submitted to the local authority safeguarding teams and notified to CQC.

The providers audits did not always ensure health and safety guidelines were followed.

We have made a recommendation about the provider following current health and safety guidelines for testing water temperatures and managing Legionella.

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.

Management and staff were aware of their roles and responsibilities. The provider adhered to their legal obligations.

The provider took action to drive improvement for care planning and recording care needs to ensure staff provided care and support in an efficient way.

The service worked well with healthcare professionals to ensure people’s care needs were met.

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

The last rating for this service was good (published 19 January 2019).

Why we inspected

We received concerns in relation to an inquest response from the coroner’s office. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of Safe and well-led only.

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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Radcliffe Manor House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have made 1 recommendation in regard to maintaining safety.

We have identified breaches in relation to good governance and safe care and treatment at this inspection.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

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