CQC report explained · a nursing home
What the CQC found at Clarendon Court Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Risks to people's health and safety were assessed and recorded. Medicines were generally stored and administered safely, although one storage issue was identified and resolved after the inspection.
- Effective?
- Good
- People's needs were assessed and care was based on those assessments. Staff had training, induction, supervision and support, and people's eating, drinking and healthcare needs were monitored.
- Caring?
- Good
- Inspectors observed warm interactions and found that people were treated with dignity and respect. People and relatives spoke positively about the care.
- Responsive?
- Good
- Care plans were personalised, detailed and regularly reviewed. The home offered activities, supported relationships and worked with hospice services to provide end-of-life care.
- Well-led?
- Good
- Management systems and audits had improved and were being used to identify and make improvements. Staff felt listened to and external professionals were involved when needed.
What inspectors found, September 2019
Clarendon Court Care Home is rated Good; inspectors found safe, kind and personalised care, with some concerns about staff availability.
This was an unannounced inspection on 5 and 14 August 2019. Inspectors spoke with people living in the home, relatives and staff. They observed care and reviewed care plans, medicines records, staff files and management records.
All five areas were rated Good: safe, effective, caring, responsive and well-led. Inspectors found that risks were assessed, medicines were generally managed safely, staff were trained, and people were treated with kindness, dignity and respect.
Some people and staff felt there were not always enough staff, especially at weekends. Inspectors found that people's needs were met promptly and no evidence that staffing levels had harmed the care provided. The home had improved since its previous Requires Improvement rating and was no longer in breach of regulations.
Improved records and oversight
Care plans contained more accurate information and management audits were being used to improve the service.
“Governance systems had improved since the last inspection.” from the report
Kind and respectful care
Inspectors saw warm interactions, and people described staff as kind, caring, good and helpful.
“All of the people we spoke with were positive about the care they received” from the report
Personalised care
Care plans reflected people's current needs, preferences and communication requirements. People were involved in their care and supported to remain as independent as possible.
“Care plans were detailed and person-centred, reviewed regularly and plans were reflective of people's current needs.” from the report
Activities and relationships
People had opportunities to follow their interests, use the local community and take part in activities such as visits from children and a therapy dog.
“There were a range of opportunities for people to follow their interests.” from the report
Staff availability
minorSome people and staff felt there were not always enough staff, particularly at weekends. Inspectors found that people's needs were met promptly and saw no evidence that this had harmed care.
“There's not enough staff they always seem to be very busy. There don't seem to be as many staff at the weekend” from the report
- 01How many staff are planned to be on duty on each floor, including at weekends?
- 02How do you check that staffing levels remain enough when people's needs change or staff are absent?
- 03What was the medicines storage issue found during the inspection, and how was it resolved?
- 04How are care plans and risk records kept up to date when a person's needs change?
- 05What activities are available for a person with dementia or with particular interests and communication needs?
This was an unannounced planned inspection covering all five CQC questions, with the Safe and Well-led ratings improving from Requires Improvement and the other ratings remaining Good. This explanation was written from the published report of 6 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.
What inspectors found, August 2018
Rated Requires Improvement; inspectors found kind, person-centred care but weaknesses in safeguarding, records and quality checks.
Inspectors visited on 13 and 15 June 2018. The first day was unannounced. They spoke with people, relatives and staff, observed care, checked six care records and reviewed staffing, medicines, training, audits and the building.
People were generally positive about the home. Inspectors found kind and respectful staff, suitable training, enough food and drink, a range of activities and care based on people's needs. The home was clean and well maintained.
The main problems were that care plans and risk assessments were not always complete, signed, dated or updated. Safeguarding procedures were not followed in two examples. The home also failed to identify and correct these problems through its quality checks.
The overall rating Requires Improvement means the home was not consistently meeting the required standard. Effective, caring and responsive care were rated Good, while safe and well-led were rated Requires Improvement.
Kind and respectful care
Inspectors saw staff treating people kindly and respectfully. People and relatives gave positive feedback about the care.
“We saw that staff were kind and caring in the way that they approached people.” from the report
Training and support
Staff were up to date with mandatory training and received regular supervision and appraisals. Staff could request further training.
“We found that the provider was committed to the ongoing training and development of staff.” from the report
Activities and personal interests
People could choose from a varied programme of activities, and one-to-one support was available for people who preferred to stay in their rooms.
“There were a range of activities available which people could choose to take part if they wished.” from the report
Clean and maintained home
Inspectors found the home clean and well maintained. Equipment and fire safety checks had been carried out.
“When we looked around each unit, we saw that a high standard of cleanliness was maintained.” from the report
Incomplete care and risk records
seriousSome care plans and risk assessments did not explain current risks clearly or show the latest changes in people's needs. This included risks linked to falls and choking.
“Care plans and risk assessments did not always provide staff with clear information and guidance about potential risks and how these should be managed.” from the report
Safeguarding procedures
seriousInspectors found two examples where local safeguarding procedures had not been followed. One involved unexplained bruising and another involved an incident between two people.
“However, we found two examples where local safeguarding procedures had not been followed, which left people at potential risk.” from the report
Accidental room locking
seriousA person was accidentally locked in their bedroom for a few seconds. Inspectors were concerned about the risk to people who might not be able to alert staff.
“We were concerned about the potential risk of people being accidentally locked in bedrooms, especially those who would be unable to alert staff.” from the report
Quality checks had not worked
seriousAlthough audits were carried out, they had not brought about effective action to fix repeated problems with records and safeguarding.
“Despite the quality assurance and audit systems in place, these were not effective as care plans did not always record the needs of people adequately and safeguarding procedures had not always been followed.” from the report
Medication monitoring information
needs fixingFor one person's specialised medicine, a nurse was unsure whether required three-monthly blood tests had taken place. The nurse checked with the GP practice and said the records would be updated.
“The nurse was unsure whether the person regularly had blood tests and had to check with the GP practice.” from the report
- 01How do you make sure care plans and risk assessments are updated promptly after a fall, weight loss, choking risk or change in mobility?
- 02What is the procedure for reporting safeguarding concerns when the registered manager is not at the home?
- 03What changes have you made to prevent anyone being accidentally locked in a bedroom?
- 04How do you check that people taking medicines needing regular blood tests receive the monitoring required?
- 05What evidence can you show that your quality audits now identify and correct these problems?
This was a comprehensive inspection covering all five key questions, with the first inspection day unannounced; the report also checked progress since the previous safeguarding breach. This explanation was written from the published report of 17 August 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 Clarendon Court Care Home
3 rated inspections over 3 years: the service has held its Good rating throughout.
- September 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 10 December 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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