CQC report explained · a nursing home
What the CQC found at Clare Court Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, February 2024
Rated Inadequate and placed in special measures; inspectors found people at risk from poor safety systems, staffing concerns and inconsistent care.
This was an unannounced inspection after CQC received information about an incident and possible falls risks. Inspectors visited on 19 and 20 September 2023, spoke with people, relatives and staff, and reviewed care plans, medicines records and other documents.
The home was not consistently safe. Risk assessments, checks on people's wellbeing, falls investigations and staffing arrangements were not reliable. Inspectors also found serious injuries had not always been investigated promptly, and found inappropriate low-level restraint without proper assessment or guidance.
There were some improvements. Medicines were managed much more safely, staff induction and training had improved, and people said they enjoyed the food. However, care was not always personal, respectful or responsive, and quality checks had failed to identify or correct important problems.
The overall rating fell from Requires Improvement to Inadequate. All five areas were rated below Good, with Safe and Well-led rated Inadequate. The home is in special measures, so CQC will keep it under review and usually re-inspect within six months.
Infection control
The inspectors were assured that the home had suitable arrangements for preventing and managing infection outbreaks and for using protective equipment.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Communication
Staff understood how to communicate with people living with dementia and adapted their communication to people's needs.
“People were supported by staff who understood their communication needs.” from the report
Consent work
The home had improved its use of capacity assessments and recorded best-interests decisions. It was no longer in breach of the regulation about consent.
“Improvement has been made at this inspection and the service is no longer in breach of regulation 11.” from the report
People enjoyed the food
Although food and drink monitoring was not reliable for some people, people told inspectors that they liked the food and were offered meals suitable for their culture.
“People told us they enjoyed the food.” from the report
People were at risk of avoidable harm
seriousRisk assessments and safety monitoring were not consistently strong enough. Falls and serious injuries were not always investigated promptly, and some people could not reach their call alarm.
“Systems to assess, monitor and mitigate risk to health, safety and welfare of people using the service were not always effective.” from the report
Safeguarding and restraint
seriousSome serious injuries were not investigated when they happened. Inspectors also found low-level restraint that had not been properly assessed or explained to staff, and problems with legal authorisations for deprivation of liberty.
“Systems had failed to safeguard people from the risk of abuse and improper treatment.” from the report
Staffing levels
seriousPeople, relatives and most staff reported staffing concerns. On one occasion it took 18 minutes to find a free carer to help someone.
“Systems to ensure people were supported by appropriately checked and safe numbers of staff were not robust.” from the report
Limited activities
needs fixingPeople, especially those cared for mainly in their rooms, were left without enough to do for long periods. This increased the risk of isolation and poorer mental wellbeing.
“People were not provided with sufficient means to engage and stimulate them through the day.” from the report
Privacy and dignity
needs fixingInspectors saw staff entering rooms without knocking and some people were not supported in a dignified way. There were also examples of people being ignored or left without clear wellbeing checks.
“We saw some examples of people's privacy and dignity not being respected.” from the report
Weak quality checks
seriousThe home's monitoring systems did not identify or correct repeated problems with weight loss, choking risks, falls, staffing and the cleanliness of carpets.
“Quality assurance systems had failed to ensure risks to people were reviewed in a timely manner to prevent further risks.” from the report
- 01What has changed since the inspection to prevent falls and ensure serious injuries are investigated and reported promptly?
- 02How many staff are planned for each floor and shift, and how do you check that staffing is enough when people need help?
- 03How are call bells, wellbeing checks, weight loss and choking risks now recorded and reviewed?
- 04What safeguards are now in place to prevent inappropriate restraint and to keep deprivation of liberty authorisations up to date?
- 05What activities are now available, especially for people who spend most of their time in their rooms, and how are complaints followed up?
This was an unannounced comprehensive inspection covering all five key questions, prompted partly by concerns about falls and other risks; the home was also checked for infection prevention and control. This explanation was written from the published report of 3 February 2024 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, September 2022
Rated Requires Improvement; inspectors found risks with medicines, staffing, care planning and management systems, with four regulations breached.
This was an unannounced focused inspection on 8 and 9 June 2022. Inspectors spoke with people, relatives, staff and other professionals. They reviewed care plans, medicine records, staff files, policies and checks of the home.
The home was not always safe or effective. Medicine records contained errors, some medicine competency checks were incomplete, and food and fluid monitoring for people at risk of weight loss was inconsistent. Some people also lacked clear risk assessments and timely support.
Care plans did not always include people's preferences, life history, cultural or spiritual needs. People and relatives were not always involved in care planning. Staff training, supervision and support were also not consistent, and the home relied on agency staff because recruitment was difficult.
The overall rating remained Requires Improvement, as did Safe and Well-led. Effective changed from Good to Requires Improvement. Caring and Responsive were not inspected, so their previous ratings were carried forward.
Choking risk
The provider had taken effective action to improve how people at risk of choking were supported.
“We found the provider had taken effective action to improve care for people with choking risk.” from the report
Food
People spoke positively about the food. Meals included fresh fruit and vegetables, and culturally appropriate meals were provided.
“Meals were cooked from scratch and people were offered regular fresh fruit and vegetables to support a healthy balanced diet.” from the report
Infection precautions
Inspectors were assured about several infection control measures, including visitors, protective equipment, testing and the infection prevention policy.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Safeguarding
Staff had received training about recognising and reporting abuse and had worked with health professionals when concerns arose.
“Staff had received training in and understood how to recognise and report abuse.” from the report
Medicines
seriousSome medicine administration records were incomplete. A medicine was given without the required health check being recorded, and one bottle had no opening date.
“This meant staff could not evidence whether it was appropriate to administer the medication.” from the report
Nutrition monitoring
seriousFood and fluid records for people at risk of losing weight were inconsistently completed. This meant staff could not be sure whether people were eating and drinking enough.
“This left people at risk of further deterioration.” from the report
Staff training and support
seriousSome staff had not completed required training or received supervision and appraisals for more than a year. Difficult recruitment also led to regular agency use and extra shifts for existing staff.
“Some staff had not received the support, supervision and training necessary to ensure they were able to carry out their duties.” from the report
Care plans
needs fixingCare plans lacked important details about people's preferences, history, cultural and spiritual needs. People and relatives were not always involved in developing them.
“This meant staff lacked vital information which could help them understand people's preferences and ensure they were being cared for in line with their wishes.” from the report
Consent and legal safeguards
seriousAt least one person's mental capacity had not been assessed and the home had not applied for the required legal authorisation. Staff were unclear about who could make decisions and who was subject to safeguards.
“This meant staff had no legal authority to keep them at Clare Court Care Home.” from the report
Management oversight
seriousAudits and checks failed to find or resolve several problems, including medicine records, care plans, training, supervision and environmental risks such as an odorous carpet.
“Systems and processes to monitor health and safety were not effective and had failed to identify the issues noted during the inspection.” from the report
- 01Have all medicine administration records, opening dates and required health checks been made complete and routinely checked?
- 02Have all staff who administer medicines completed their competency assessments?
- 03How many agency staff are currently being used, and have staffing levels and consistency improved since the inspection?
- 04Has my relative's care plan been updated with their life history, preferences, cultural and spiritual needs, with their involvement or that of their family?
- 05How do you check that mental capacity assessments and any required Deprivation of Liberty Safeguards authorisations are in place?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 8 September 2022 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 Clare Court Care Home
4 rated inspections over 5 years: the service has slipped, from Good to Inadequate.
- February 2024Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2022Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- January 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- October 2018GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016
Registered with the Care Quality Commission on 9 December 2016.
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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