CQC report explained · a residential care home
What the CQC found at Clarendon Beechlands
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, May 2023
Rated Inadequate and placed in special measures; inspectors found serious safety, staffing and leadership failures.
This was an unannounced inspection over three days. Inspectors spoke with people living at the home, relatives and staff. They reviewed care plans, risk assessments, medicine records, audits, policies, training records and recruitment files.
The home was not consistently safe. There were too few staff, gaps in training and problems with medicines, risk assessments and infection control. One person was subject to restrictions without the required legal authority. Some areas were dirty or poorly maintained.
The home also needed improvement in how it provided effective, caring and responsive support. People did have access to healthcare, activities and visits, and some people said they were happy. However, care records, food arrangements, involvement in decisions, complaints and support with relationships were not always good enough.
The overall rating fell from Good at the previous inspection, published in September 2019, to Inadequate. The home was placed in special measures, meaning CQC will monitor it closely and normally re-inspect within six months.
Healthcare access
People were supported to see healthcare professionals, including doctors, dentists, opticians and a chiropodist. Staff also supported people to attend appointments.
“People had access to healthcare support when required.” from the report
Activities and choice
People took part in activities such as karaoke and dominoes. They were supported to attend day centres, go out and visit places important to them.
“There was a good mix of activities and people were observed to participate in the activities, such as karaoke, and dominoes.” from the report
Visitors welcomed
Relatives said they were welcomed, and the provider reported no restrictions on visiting during the inspection.
“Relatives told us they were welcomed into the home to visit their loved ones.” from the report
Some positive experiences
Most people chose to attend monthly residents' meetings, and people gave positive comments about living at the home.
“People's feedback of living at the service was good.” from the report
Unsafe staffing
seriousThere were not enough staff to meet people's needs. On eight occasions in January, there were not enough medicine-trained night staff for some medicines to be given after 8pm.
“There were not enough staff deployed to meet the needs of the service.” from the report
Medicine and risk failures
seriousSome as-required medicine protocols were missing or incomplete. Diabetes and blood-thinning medicine risks were not properly assessed or explained to staff.
“Medicine records were not always accurate and risks with medicines had not always been assessed.” from the report
Unlawful restrictions
seriousA person was restricted without the required legal authority, and staff did not report or challenge the practice. The report says this continued for an extended period.
“The deprivation of a person's liberty for the purpose of receiving care or treatment without lawful authority was a breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Training gaps
seriousMedicine competency checks were out of date for all seven medicine-trained staff. Several staff also lacked current training in fire safety, first aid, moving and handling, learning disabilities and autism.
“Staff did not have the necessary training nor assessments to ensure they were competent to undertake their role.” from the report
Poor cleanliness and repairs
needs fixingMould was found in three en-suite wet rooms. Inspectors also found dirty or damaged surfaces, chipped paintwork and other maintenance problems.
“Mould was found growing in en-suite wet rooms in bedrooms belonging to 3 people.” from the report
Weak management oversight
seriousAudits did not identify or address important problems. Incidents were not always reported to CQC, and action was not always taken to prevent them happening again.
“The provider had failed to operate effective quality assurance systems to assess and monitor the safety and quality of people's care.” from the report
- 01How many staff are now working on each shift, including how many are trained and assessed to give medicines?
- 02What has been done to make sure all restrictions on people's liberty are legally authorised, reviewed and recorded?
- 03Have all staff completed current training in medicines, fire safety, first aid, moving and handling, learning disabilities and autism?
- 04Have the mould, damaged surfaces, chipped paintwork and other maintenance problems been fully repaired?
- 05How are audits, incidents, complaints, weight loss and care-plan changes now checked by managers?
This was an unannounced inspection that assessed all five key questions and looked at both the premises and care; the previous ratings were Good in 2019. This explanation was written from the published report of 6 May 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, September 2019
Rated Good; inspectors found safe, kind and personalised care, with some improvements needed around independence, complaints and infection control.
This was an unannounced planned inspection on 19 August 2019. Two inspectors observed care, spoke with people living in the home and staff, and checked care records, medicines, staffing, training and management records.
The home provided personal care for 18 people with learning disabilities and autism. Inspectors found people were safe, treated with kindness and involved in decisions about their care. Medicines were managed safely, staffing levels were suitable and care plans were detailed.
The overall rating was Good, and all five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors made recommendations about helping people build independence, how complaint responses are communicated and the risk of cross infection in the laundry room.
Safe medicines and staffing
Inspectors found medicines were administered safely and staffing levels were suitable for people's physical and emotional needs.
“Staff rotas demonstrated staffing levels were suitable to meet people's physical and emotional needs.” from the report
Kind and respectful care
People were treated with kindness and compassion. Staff respected privacy and dignity, including by knocking before entering bedrooms.
“We observed staff respected people's privacy and dignity, and heard staff knocking on people's bedroom doors before announcing themselves and entering.” from the report
Personalised care
Care plans contained detailed information about people's needs, history, preferences and aspirations. Staff showed they understood individual needs.
“There was detailed information about people's past history, likes, dislikes, wishes and aspirations and an up to date photograph in people's files.” from the report
Support for choice and independence
People were involved in decisions about their care and supported to follow hobbies, use self-help skills and access the community.
“People were supported to follow their hobbies or interests and there was evidence where a person's self-help skills had been used to support a move to independent living.” from the report
Laundry and independence
needs fixingPeople could not launder their own clothes without accessing the cellar. Inspectors recommended reviewing this so the home could better support independence and transition to supported accommodation.
“However, people were unable to launder their own clothes without accessing the cellar of the home.” from the report
Laundry infection control
needs fixingInspectors asked the provider to consider the potential for cross infection in the laundry room.
“We recommend the provider consider the potential for cross infection in the laundry room.” from the report
Complaint responses
needs fixingThe home had received six complaints in the previous 12 months and had responded in writing to most complainants. Inspectors recommended reviewing how responses were communicated.
“We recommend the provider consider how responses are communicated to complainants.” from the report
- 01What has been done to reduce the potential for cross infection in the laundry room?
- 02How can residents develop laundry and other independence skills without needing to access the cellar?
- 03How are complaint responses now communicated to people and their representatives?
- 04What activities are currently available in the home, and how are residents' choices used to plan them?
- 05How do you support people who may want to move into supported accommodation?
This was an unannounced planned inspection covering all five CQC questions; all five ratings remained Good from the previous inspection. This explanation was written from the published report of 25 September 2019 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 Clarendon Beechlands
4 rated inspections over 7 years: the service has slipped, from Requires improvement to Inadequate.
- May 2023Inadequatecurrent ratingdown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 January 2011.
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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