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.
What inspectors found, August 2023
Requires Improvement; safety and management had improved, but some risks and activities still needed closer attention.
Inspectors made an unannounced visit on 18 July 2023. They spoke with 6 people, received written feedback from 6 relatives, spoke with 9 staff and reviewed care, medicines, recruitment and management records.
The home had improved since its previous inspection. Medicines were stored and given safely, recruitment checks had improved, the home was clean and new systems were being used to review incidents, complaints and care.
However, some identified risks did not have clear guidance for staff. People also had too few activities, and inspectors could not yet be sure that the new systems would remain reliable. The overall rating stayed Requires Improvement. Safe improved to Requires Improvement, while Well-led remained Requires Improvement.
Safer medicines
Medicines were stored safely and given as prescribed. Staff had training and were checked as competent before administering medicines.
“Improvements had been made since our last inspection and medicines were managed safely.” from the report
Improved risk checks
The home had improved its assessments of falls, skin problems and movement risks. Care plans gave staff guidance in many of these areas.
“Care plans provided guidance to staff to reduce the likelihood of harm.” from the report
Cleaner home
Inspectors found the home clean and tidy. More housekeepers had been employed to help keep it clean.
“On the day of inspection, we found the home was clean and tidy.” from the report
Safer recruitment
Recruitment checks had been strengthened, including the required checks before staff started work.
“Appropriate Disclosure and Barring Service (DBS) checks had been made.” from the report
Supportive management
Staff said the registered manager was approachable and supportive. Inspectors also saw friendly interactions and found the manager knew people and their needs.
“Staff told us they found the registered manager approachable and supportive.” from the report
Some risks lacked clear instructions
seriousSome people were assessed as being at medium or high risk of physical abuse to others, self-neglect or agitation, but their care plans did not explain how staff should reduce these risks.
“Care plans did not contain guidance to instruct staff how to reduce the risk.” from the report
Systems not yet proven
needs fixingInspectors saw improvements in medicines, safeguarding and management checks, but could not yet confirm that these systems would remain reliable over time.
“We were unable to assess at this inspection whether the systems put in place since our last inspection would be embedded and maintained.” from the report
Too few activities
needs fixingThe home did not have an activities coordinator during the visit. People and relatives reported that there had been little stimulation, and a new staff member was expected to start.
“Unfortunately, the home did not have an activities co-coordinator at the time of our inspection but were awaiting a new member of staff to start.” from the report
Staffing concerns at some times
needs fixingInspectors saw enough staff on the day, but some relatives said staffing was not always sufficient, including on Sundays.
“Finding staff is sometimes an issue, especially on Sundays when I tend to visit.” from the report
- 01What written guidance is now in place for my relative's identified risks, including agitation, self-neglect or risk of harm to others?
- 02How often will activities take place, and who is responsible for providing them?
- 03How will you show that the new medicines, incident and care monitoring systems remain reliable over time?
- 04How can families raise concerns, and when will they receive updates about their relative's care?
- 05What staffing levels are planned at weekends, especially on Sundays?
This was a targeted inspection to check Warning Notices about Safe and Good governance, widened to a focused inspection of Safe and Well-led; the other three key question ratings carried over from the previous inspection. This explanation was written from the published report of 5 August 2023 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 2023
Rated Requires Improvement, with Safe rated Inadequate; inspectors found kind care but serious risks in medicines, safeguarding and management.
Inspectors visited unannounced on 8, 10 and 14 March 2023. They spoke with people living at the home, relatives, staff and health professionals. They reviewed care plans, medicines records, recruitment files and management records.
The home was caring, and staff treated people with kindness, dignity and respect. People had their needs assessed before moving in, enjoyed the food overall, and were supported to access healthcare. However, inspectors found people were at risk because medicines and health risks were not always managed safely.
There were also problems with safeguarding reports, care plans, activities, staff training, infection control and management checks. The overall rating was Requires Improvement. Safe was Inadequate, while Effective, Responsive and Well-led were Requires Improvement, and Caring was Good.
This was the first inspection of the newly registered service. The home had a new provider and management team and was undergoing changes. The previous provider had been rated Good in July 2018, but that was before the current registration.
Kind and respectful staff
Staff knew people well and supported them patiently when they were distressed. People and relatives described staff as kind, caring and respectful.
“Staff were kind and caring and treated people with dignity and respect.” from the report
Food and special diets
Meals were nutritious and well presented. The kitchen catered for special diets and staff knew people's preferences and nutritional needs.
“We observed meals to be nutritious and well presented. People with special diets including set consistency diets had been catered for.” from the report
Healthcare support
Staff contacted healthcare professionals when people needed medical attention. People were also supported with appointments and access to visiting professionals.
“Healthcare professionals told us staff followed instructions given to them to improve the lives of people using the service.” from the report
Mental capacity and consent
The home sought consent and completed capacity assessments and best-interest decisions when needed. Deprivation of Liberty Safeguards applications had been made appropriately.
“Records showed us that DOLs applications had been made as appropriate.” from the report
Medicine safety
seriousSome medicines were not stored, administered or recorded safely. This included risks involving blood-thinning medicines, medicines given when required, fridge and room temperatures, creams and out-of-date eye drops.
“People had been placed at risk of harm from medicines that were not managed properly and safely.” from the report
Unmanaged health risks
seriousRisk assessments did not always explain how staff should support people with diabetes or prevent pressure sores. Repositioning and pressure-relieving equipment checks were not always completed, and unexplained marks were not always investigated.
“Risks to people's health, safety and welfare had not always been assessed and when they had been, risk assessments did not always contain information to direct staff on how to manage those risks.” from the report
Safeguarding notifications
seriousThe home did not always follow local safeguarding procedures or report incidents to the local safeguarding team. This meant outside checks could not always take place.
“The local safeguarding policy had not always been followed and incidents had not always been reported to the local safeguarding team.” from the report
Care plans and records
needs fixingCare plans did not always describe people's needs or include information recorded in reviews. Daily notes were sometimes missing or too brief, putting people at risk of not receiving the right care.
“Care plans did not always reflect the person or had important information recorded in separate reviews that had not been added to the care plan.” from the report
Activities and stimulation
needs fixingThere was only one activities worker for the home, and some days had no activities staff. People staying in their rooms did not always receive extra one-to-one time or access to activities.
“People did not always have access to social activities.” from the report
Weak management checks
seriousAudits and other management systems did not identify or address important problems. The home was also affected by staffing changes and the registered manager covering several operational roles.
“Governance systems established by the provider were neither robust nor effective.” from the report
- 01What has changed to make sure medicines are stored at the correct temperatures, given as prescribed and recorded properly?
- 02How are risks such as diabetes, pressure sores, repositioning and unexplained marks now assessed and monitored?
- 03How do you make sure all safeguarding incidents are reported promptly to the local safeguarding team?
- 04Have all residents' care plans been rewritten with their views and relatives' input, and how do staff access the latest information?
- 05What activities and one-to-one support are now available for people who stay in their rooms?
This was the first comprehensive inspection of the newly registered service, covering all five key questions and infection prevention and control. This explanation was written from the published report of 27 April 2023 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
2 rated inspections over a year: the service has held its Requires improvement rating throughout.
- August 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2023Requires improvementSafe: InadequateWell-led: Requires improvement
- January 2022
Registered with the Care Quality Commission on 17 January 2022.
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
15 live-in carers within about an hour of Dorset
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 £1,040 to £1,340 a week. 11 can care for a couple. 10 years' experience on average.
“Even when things get a bit chaotic (as they sometimes do!), you’ve handled it with patience and a sense of humour — which is gold.”
“Nina was patient, focussed on my aunt's physical well-being, and unfazed by what at the time was a new and uncertain situation”
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.