CQC report explained · a residential care home
What the CQC found at Clarence House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were managed well, medicines were administered safely, and safeguarding and recruitment systems were in place. Some staff needed reminders to wear protective equipment correctly.
- Effective?
- Good
- This question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Caring?
- Good
- This question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Well-led?
- Good
- Inspectors found the home was consistently managed, with good quality checks, regular meetings and an open culture. Some care-plan wording needed improvement and was actioned immediately.
What inspectors found, November 2022
Rated Good; inspectors found safe, person-centred care, with some records and infection-control practice needing attention.
This was an unannounced, focused inspection on 18 October 2022. Inspectors looked only at Safe and Well-led. They spoke with people, relatives and staff, observed care, and checked care records, medicines, training and management systems.
The home was rated Good for Safe and Good for Well-led. Inspectors found risks were managed, medicines were given safely, staffing was generally sufficient, and safeguarding systems were in place. People said they felt safe and were listened to.
People were supported to take part in activities they enjoyed and to develop their skills and interests. Inspectors saw positive relationships between people and staff, and found an open culture where concerns could be raised.
There were some minor shortfalls. Staff sometimes needed reminders about wearing protective equipment. Some care plans were not written from the person's point of view, although this was corrected immediately. The other three ratings were carried forward from the previous inspection.
Safe medicines
Medicines were available, given on time and recorded without gaps. Staff responsible for medicines were trained and checked for competence.
“People's medication was always available, administered on time and there were no gaps in the medication administration records.” from the report
People's interests
People took part in activities they enjoyed, including activities that supported skills and learning.
“People told us they were able to lead fulfilling lives and develop their interests.” from the report
Positive relationships
People said staff listened to them, and inspectors observed positive interactions between people and staff.
“We observed positive interactions between people and staff.” from the report
Protective equipment reminders
minorDuring a COVID-19 outbreak, some staff needed reminders from the registered manager to wear protective equipment properly.
“some staff had to be reminded at times by the registered manager to wear their personal protective equipment appropriately.” from the report
Care-plan wording
needs fixingSome parts of care plans were not written from the person's point of view. The home reviewed this immediately after inspectors raised it.
“some areas of people's care plans were not always written from people's point of view.” from the report
Agency staff workload
minorSome staff said managing the workload was sometimes difficult when agency staff were working. The manager described extra induction arrangements and ongoing recruitment.
“Some staff told us there were enough staff but when agency staff were on shift, it was sometimes hard to manage the workload.” from the report
- 01How do you check that every care plan is written from the person's own point of view?
- 02What has changed to make sure all staff wear protective equipment correctly during an infection outbreak?
- 03How do you manage the workload when agency staff are on shift?
- 04How can people access areas such as the kitchen and garden, and how do you make sure these arrangements are not unnecessarily restrictive?
- 05How do you make sure emergency medicines are available when people are out in the community?
This was a focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings were carried forward from the previous inspection published on 7 June 2018. This explanation was written from the published report of 18 November 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.
What inspectors found, June 2018
Rated Good; inspectors found safe, kind and person-centred care, with some management and record-keeping gaps still being addressed.
This was an unannounced inspection on 21 March 2018. Inspectors observed care, spoke with people living at the home, staff and community professionals, and checked care records, recruitment files, incident records, maintenance records and audits.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People told inspectors they felt safe. Staff understood safeguarding, risk assessments were individual, staffing levels met assessed needs and medicines were generally managed safely.
Inspectors found warm relationships between staff and residents. People were supported to make choices, stay independent, access healthcare, eat food they liked and take part in activities. Care plans were detailed and tailored to each person.
The provider had improved building maintenance, cleanliness and governance since the previous inspection in November 2016. Some minor problems remained, including overdue medicine competency checks, an out-of-date training overview and occasional gaps in incident records. A registered manager was not in post at the time.
Individual risk planning
Risk assessments covered people’s specific needs and aimed to keep them safe while supporting independence. Staff understood the behaviour support plans and how to reduce risks.
“Risk assessments were individual to people's needs and minimised risk whilst promoting people's independence.” from the report
Kind and respectful care
Inspectors saw warm relationships and a relaxed atmosphere. Staff supported privacy, dignity, personal preferences and independence.
“We observed staff speak to people gently or with appropriate humour and banter and they were kind and compassionate.” from the report
Detailed care planning
Care plans covered health, communication, personal preferences, relationships, activities and longer-term goals. They were reviewed when people’s needs changed.
“We found care plans were person-centred and explained how people liked or didn't like to be supported.” from the report
Support with health
People were helped to attend a wide range of health appointments and had health action plans and hospital passports.
“People were supported to access external health professionals and we saw this had included GP's, psychiatrists, community nurses, psychologists, chiropodists, dentists and opticians.” from the report
Medicine competency checks
needs fixingNot all staff had a refreshed medicine administration competency check within the previous year. Management said completing these was a priority.
“Not all medicines competency checks had been completed again in the last year.” from the report
Staff training records
needs fixingThe training overview was not up to date, although inspectors saw certificates for the required training. An updated training matrix was sent after the inspection.
“The overview of staff training (training matrix) was not up to date; however we saw training certificates for all required training.” from the report
Management cover
needs fixingThere was no registered manager after the previous manager left. The regional operations manager was running the service while a replacement was being recruited, and some governance gaps remained.
“A registered manager was not in place as they had recently left the service, and applied to de-register as manager.” from the report
Minor premises issues
minorThe building was generally clean and safe, but some extractor fans and radiator covers needed attention. One kitchen needed updating and a fridge seal was broken, although the fridge freezer was replaced immediately after the inspection.
“There were still some minor maintenance issues, for example; the kitchen in one unit was in need of updating, the seal on the fridge was broken” from the report
Incident recording
needs fixingOccasionally, a behavioural incident appeared in daily records without a separate incident form. Management said this had been followed up with staff.
“We saw occasionally a behavioural incident had been recorded in the daily records, and an associated incident form had not been completed.” from the report
- 01Have all staff now completed and passed their refreshed medicine competency checks?
- 02Is the staff training matrix now fully up to date, and how is it checked?
- 03Who is currently responsible for managing the home while a new registered manager is recruited?
- 04Have all minor maintenance and cleaning issues, including the kitchen update, been completed?
- 05How does the home make sure every behavioural incident is recorded on the correct incident form?
This was an unannounced comprehensive inspection covering all five CQC questions, with follow-up checks on improvements requested after the November 2016 inspection. This explanation was written from the published report of 7 June 2018 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
4 rated inspections over 8 years: the service has held its Good rating throughout.
- November 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- January 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 19 November 2010.
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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At least 100 live-in carers within about an hour of Kirklees
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. 86 can care for a couple. 11 years' experience on average.
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