CQC report explained · a nursing home
What the CQC found at Clare Mount
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
Requires Improvement; inspectors found improvements in medicines and staffing, but serious safety and management weaknesses remained.
This was an unannounced focused inspection on 11 January 2024. Inspectors looked only at Safe and Well-led, after concerns about staffing, communication, safety and person-centred care. They spoke with people, relatives and staff, and checked care, medicines, recruitment, training, maintenance and management records.
The home had enough staff when inspectors visited. Safeguarding arrangements were in place, medicines were managed well, and staff had suitable training. Relatives spoke positively about staff and said communication had improved.
However, important fire safety, electrical and passenger lift work had not been completed. Infection control checks needed improvement, and some areas needed refurbishment. Management audits had not identified these risks. The home was rated Requires Improvement for Safe and Well-led, and remains Requires Improvement overall.
Medicines
Medicines audits had improved. Records were accurate, administration records were fully signed, and inspectors found no discrepancies in medicines remaining on site.
“Medicine records were reviewed regularly and records were accurate.” from the report
Staffing and safeguarding
There were enough staff on duty during the visit, and staff understood their safeguarding responsibilities. Relatives generally felt people were safe.
“There were sufficient numbers of staff to provide care and support to people promptly.” from the report
Staff support and communication
Relatives said communication had improved and described the staff and management positively. Staff said they had good working relationships and felt supported.
“Relatives were complimentary about the staff and management team and said communication had improved.” from the report
Outstanding safety work
seriousHigh-priority fire safety work had not been completed. Remedial work identified in the electrical installation report and passenger lift report also remained outstanding, creating a risk of harm.
“This placed people at risk of harm. This was a breach of Regulation 12 (safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Weak management checks
seriousAudits and management oversight had not identified important environmental safety and infection control problems. The provider had not consistently completed recommended actions.
“The provider had failed to ensure systems for governance and management oversight were robust and effective.” from the report
Cleaning and refurbishment
needs fixingSome bathrooms, flooring and skirting boards were not clean. Poor wall and flooring conditions made thorough cleaning difficult, and cleaning schedules were not consistently completed.
“Bathrooms could not be thoroughly cleaned due to the poor condition of some walls and flooring.” from the report
- 01Has the high-priority work to the roof voids and other fire safety recommendations now been completed and checked?
- 02What remedial work was required by the electrical installation report, and has the installation been made satisfactory?
- 03What work was needed after the passenger lift service report, and is the lift now safe to use?
- 04What refurbishment and cleaning changes have been made in the bathrooms, lounge and other areas?
- 05How will managers make sure their audits identify safety and infection control problems promptly?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous inspection. This explanation was written from the published report of 13 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, July 2022
Rated Requires Improvement and no longer in Special Measures; inspectors found kind, effective care and better leadership, but medicines records and some building repairs still needed attention.
This was an unannounced follow-up inspection on 6 and 7 July 2022. Inspectors spoke with people living at the home, relatives and staff. They reviewed care plans, medicines records, recruitment and training records, safety checks, complaints and quality audits.
The home had improved since its previous inspection, which was rated Inadequate. People were supported by kind staff who knew them well. Their care plans were detailed, their health and food needs were met, and activities and family involvement were encouraged.
Some safety and management work was not fully finished. Medicines records and guidance needed more auditing and updating. A loose handrail and worn carpet had not been dealt with, and other records and improvements needed to be kept up to date. The home was no longer in breach of regulations and was no longer in Special Measures, but it still needs to show that improvements are sustained.
Kind and respectful staff
Inspectors saw staff treating people with kindness, patience and respect. Staff knew people well and supported their dignity and independence.
“Throughout the inspection staff were observed to be kind and caring.” from the report
Personalised care
Care plans and risk assessments gave staff useful information about what mattered to each person and how they wanted to be supported.
“Person-centred support plans and risk assessments, that reflected what was important to and for the person, were in place to guide staff.” from the report
Improved staff training
Staff had received more detailed training and said it had improved their confidence and the quality of care.
“Staff received the induction, training and support they needed to carry out their roles effectively.” from the report
Activities and family involvement
There was a range of activities, including singing, exercise and skittles. Relatives said they felt welcome and involved in care.
“We saw a range of activities were on offer.” from the report
Improved oversight
The home had strengthened its quality checks and management arrangements since the previous inspection. People, relatives and staff spoke positively about the changes.
“Systems for auditing and quality monitoring and oversight had been improved.” from the report
Medicines information
needs fixingPeople received medicines as prescribed, but staff did not always have enough information about medicines hidden in food or drink. The medicines policy also needed updating.
“Where people were having their medicines covertly, hidden in food and drink, staff did not always have information about how to administer the medicine.” from the report
Unfinished building repairs
needs fixingA loose handrail and worn carpet identified by an earlier safety audit had not been dealt with by the inspection. Further decoration and improvements were also still needed.
“A health and safety audit; (which the registered manager had commissioned in January 2022), had identified a loose handrail and worn carpet. This had not been addressed at the time of our inspection.” from the report
Improvements not yet proven over time
needs fixingThe home had made progress, but inspectors had not yet seen a long enough record showing that the new systems and improvements would continue to work well.
“The systems and improvements we saw during our inspection needed to be embedded further and required a longer-term track record of sustained improvement and good practice.” from the report
- 01How do you now check that medicines hidden in food or drink are administered in the correct way?
- 02Has the medicines policy been updated to include current legislation and guidance?
- 03Have the loose handrail and worn carpet identified by the safety audit now been repaired?
- 04How do you check that the improvements found at this inspection continue over time?
- 05What recent training have staff completed, and how do you check that it has improved their practice?
This was an unannounced follow-up inspection after an earlier Inadequate rating; it considered the overall service, including care, premises, medicines, infection control and management systems. This explanation was written from the published report of 27 July 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 Mount
5 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- February 2024Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2022Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- June 2022Inadequatedown from GoodSafe: InadequateEffective: InadequateResponsive: InadequateWell-led: Inadequate
- January 2021Goodup from Requires improvementSafe: GoodResponsive: GoodWell-led: Good
- January 2020Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2018
Registered with the Care Quality Commission on 20 December 2018.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Rochdale
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 92 can care for a couple. 11 years' experience on average.
“Primrose is a very kind and compassionate healthcare professional”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.