CQC report explained · a nursing home
What the CQC found at Clarence House 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, January 2024
Requires Improvement; inspectors found infection risks, unsafe care planning and weak oversight, alongside some caring and staffing strengths.
This was an unannounced focused inspection on 14 November 2023. Inspectors spoke with people, relatives and staff, observed care, and reviewed care records, medicine records and quality checks.
The home was not always safe. Inspectors found unclean areas, gaps in information about people's nutritional needs and problems with medicine recording. They also found that people did not always receive personalised care, dignity and respect, and that relatives were not always listened to.
The home was rated Requires Improvement overall. Safe, caring and well-led were all rated Requires Improvement. Effective and responsive were not inspected, so their previous ratings were carried forward. The provider took action after the inspection, but CQC said the new systems still needed to become established in everyday practice.
Staffing and recruitment
Inspectors found enough suitable staff available and saw evidence of safe recruitment processes.
“The provider ensured there were sufficient numbers of suitable staff.” from the report
Safeguarding awareness
Staff said they understood how to recognise and report possible abuse. The home also kept records of safeguarding concerns and actions taken.
“Staff we spoke with told us they knew people well and would recognise if there were signs of abuse.” from the report
Medicines mostly given correctly
People predominantly received their medicines as prescribed. The main problem found was with recording.
“Predominantly, people received their medicines as prescribed by staff who were trained and competent in the safe handling of medicines.” from the report
Choice and least restriction
Inspectors found that people were supported to make choices and that the home was working in line with the Mental Capacity Act.
“People were supported to have maximum choice and control of their lives” from the report
Cleanliness and infection control
seriousSeveral areas, including bathrooms, toilets, a kitchenette and some ensuite facilities, were unclean. Inspectors said this put people at risk of cross infection.
“The provider had failed to provide a clean environment and people were put at risk of cross infection.” from the report
Care risks and care planning
seriousSome risks were identified but not managed safely. Nutritional care plans did not always explain people's needs or how staff should help them.
“The provider had failed to ensure risks were managed to ensure peoples safety.” from the report
Personalised care and dignity
needs fixingCare was often task-focused. Inspectors heard concerns about drinks being out of reach, bathing, personal care and staff discussing people's care loudly.
“People did not always receive person centred care.” from the report
Weak quality oversight
seriousThe provider's monitoring systems had not identified several problems, including infection control, risks and medicines management. Inspectors also found poor involvement and communication with relatives.
“We identified a lack of person centred care, leadership, engagement and ineffective management systems.” from the report
- 01What action has been taken to keep bathrooms, toilets, kitchenettes and ensuite facilities clean, and how is this checked now?
- 02How will you make sure each person's nutritional risks and support needs are clearly recorded and followed by staff?
- 03How will you ensure drinks, bathing, nail care and other personal care are provided in line with each person's preferences?
- 04What changes have been made to medicine records, and how are errors or missing entries identified?
- 05How will relatives be involved in care planning, meetings and checking whether improvements are working?
This was a focused inspection of Safe, Caring and Well-led only; Effective and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 19 January 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, April 2021
Clarence House Care Home was inspected but not rated; inspectors were assured that infection risks were being managed.
This was an announced, targeted inspection on 18 March 2021. It focused on infection prevention and control during the coronavirus pandemic, rather than the home's overall quality.
Inspectors found systems for visitors, including screening, temperature checks, hand sanitising, PPE and social distancing. Staff were trained in infection control, and supplies of PPE were available.
The home supported contact with relatives through telephone and video calls, window visits and a visiting pod. Inspectors also found the home clean, hygienic and well ventilated, with testing and outbreak plans in place.
The service was marked 'Inspected but not rated'. This means the inspection checked infection control arrangements but did not give a new overall rating or a full set of ratings for the five areas of care.
Visitor infection controls
Visitors were screened and supervised, and facilities were available for hand sanitising and putting on PPE.
“Effective systems were in place to ensure visitors to the service followed government guidelines for wearing Personal Protective Equipment (PPE).” from the report
Contact with relatives
The home offered several ways for people to stay in touch with relatives, including a separate visiting pod.
“People were supported to maintain contact with their relatives in different ways including telephone and video calls, and window visits.” from the report
Clean environment
Inspectors found the environment clean, hygienic and well ventilated, with cleaning schedules being followed.
“The environment was clean, hygienic and well ventilated.” from the report
Outbreak planning
The home had an up-to-date infection control policy and a plan for managing a COVID-19 outbreak.
“The service had plans in place and knew how to respond to an outbreak of infection to ensure the safety of people and staff.” from the report
Inspectors raised no specific concerns in this report.
- 01How are visits and contact with relatives managed now, including contact visits and any visiting pod arrangements?
- 02How do you make sure staff continue to use PPE safely and have enough supplies?
- 03How often are people living here and staff tested, and what happens after a positive result?
- 04What is the current plan for preventing and managing an infection outbreak?
- 05How do you safely admit new people to the home?
This was a targeted inspection of infection prevention and control during the coronavirus pandemic; it did not provide a full overall rating or ratings for the other areas of care. This explanation was written from the published report of 1 April 2021 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 Clarence House Care Home
2 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- January 2024Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- April 2021Inspected but not ratedSafe: Inspected but not rated
- August 2017GoodSafe: GoodCaring: GoodWell-led: Good
- November 2016
Registered with the Care Quality Commission on 25 November 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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