CQC report explained · a residential care home
What the CQC found at Clarendon House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm. Inspectors found enough staff, safer medicines management, individual risk assessments and safeguarding systems, but recruitment checks had not always been fully completed.
- Effective?
- Good
- This question was not inspected during this focused visit, so the report does not give a current rating for it.
- Caring?
- Good
- This question was not inspected during this focused visit, so the report does not give a current rating for it. Inspectors did record that staff treated people with dignity and respect.
- Responsive?
- Good
- This question was not inspected during this focused visit, so the report does not give a current rating for it.
- Well-led?
- Good
- Management and quality monitoring had improved. Audits were up to date, lessons were taken from incidents and the provider had oversight of the home.
What inspectors found, January 2023
Clarendon House rated Good; inspectors found safe, caring support and better management, but recruitment checks were not always complete.
This was an unannounced focused inspection on 28 December 2022 and 4 January 2023. One inspector spoke with people living at the home, relatives, staff and health and social care professionals. They also checked care records, medicines records, staff files and management records.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safer medicines systems, updated risk assessments and effective safeguarding arrangements. People and relatives said they felt safe, and staff treated people with kindness and respect.
Some recruitment checks had not been completed properly, although the provider acted during the inspection. Staff also did not initially follow the home's visitor PPE policy, but this was corrected immediately. The overall rating improved from Requires Improvement at the previous inspection because the provider had acted on earlier concerns.
Safer medicines
Medicines were given by trained staff using safe procedures. Records were complete and matched the medicine stock.
“Medicines were managed safely and administered by trained staff. Staff followed safe procedures when giving people their medicines.” from the report
Better oversight
The home had introduced improved audits covering areas such as care planning, falls, infection and medicines. These systems helped identify lessons and actions.
“Improvements had been made and quality assurance systems had been revised. Auditing and monitoring systems had improved.” from the report
Kind and respectful care
People and relatives described staff as caring and said staff understood people's individual needs and preferences.
“The staff are all so caring, they give you so much warmth and feeling, it makes you feel good.” from the report
People's views used
People were asked for their views through house meetings, and feedback led to changes such as replacing low sofas.
“People were consulted in the running of the home.” from the report
Recruitment checks
needs fixingThe recruitment process was not always followed. Some staff files lacked required information, including further assessment where a staff member had a specific health condition.
“This meant that checks to ensure safe recruitment of staff were not robust.” from the report
Visitor PPE policy
minorOn the first inspection day, staff did not always follow the home's policy requiring visitors to wear PPE. The manager updated the policy and told staff what to do.
“On day one of our inspection, staff did not always follow the care home's policy.” from the report
- 01Have all recruitment files now been checked, including any required health assessments?
- 02How do you make sure staff follow the current visitor PPE and infection control policy?
- 03What audits are currently carried out, and how are families told about actions taken after incidents or accidents?
- 04What current rating or evidence can you provide for Effective, Caring and Responsive, which were not covered by this inspection?
- 05How will you make sure the number of staff on duty remains suitable if someone needs extra support or a new person moves in?
This was a focused inspection of Safe and Well-led; the other key questions were not inspected in this visit and the overall rating used earlier ratings for those areas. This explanation was written from the published report of 14 January 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, October 2021
Rated Requires Improvement; inspectors found people felt safe and supported, but safety checks, medicines guidance and management systems needed improvement.
This was a focused inspection after concerns about environmental safety, medicines and management. Inspectors visited on 8 and 11 October 2021. They spoke with people, relatives and staff, observed care, and checked care, medicines, staff and management records.
People generally felt safe, and there were enough staff. Medicines were given as prescribed, infection control was strong, and staff knew people well. However, some risk assessments and safety checks were not detailed or completed on time. Guidance for medicines taken occasionally was also missing.
Management checks did not give a reliable overview of the home. Accidents were not always recorded consistently, actions from audits were not properly managed, and formal feedback was not being sought. The overall rating fell from Good at the previous inspection in 2017 to Requires Improvement.
People felt safe
People and relatives said the home was safe and that concerns would be followed up. Staff had safeguarding training and knew how to report concerns.
“People, their relatives and staff told us Clarendon House was a safe place to be.” from the report
Medicines usually given correctly
Records showed prescribed medicines were given in line with medical advice. Staff giving medicines were trained and checked as competent.
“Records showed medicines were given in accordance with medical advice.” from the report
Strong infection control
Inspectors were assured that the home used suitable infection prevention measures, including PPE, testing, hygiene and visiting arrangements.
“We were assured that the provider was using PPE effectively and safely.” from the report
Enough suitable staff
There were enough staff on duty, and recruitment records showed appropriate checks had been completed.
“There were enough staff on duty.” from the report
Positive relationships
People, relatives and staff gave positive feedback about the home and how people were supported.
“Everyone we spoke with enjoyed the home and the people they shared it with.” from the report
Safety checks were not reliable
needs fixingSome risk assessments did not cover all relevant risks. Environmental, fire and equipment checks were not always completed on time, increasing risk even though no negative impact was found.
“Environmental risk assessments, fire safety and equipment safety checks were not always carried out on time or consistently.” from the report
Occasional medicines lacked guidance
needs fixingThe home did not have guidance for medicines people took occasionally. This meant the provider could not be sure they would always be given consistently.
“However, guidance was not in place for medicines people took occasionally.” from the report
Management systems failed to identify problems
seriousAudits were limited and did not identify the shortfalls found during the inspection. Actions were not always completed, and there was no clear timescale or named person responsible.
“Quality assurance systems did not always operate effectively.” from the report
Lessons were not consistently learned
needs fixingAccidents and incidents were recorded, but the home's policy was not followed consistently. This made it difficult to review events and use them to improve safety.
“This meant the service did not learn from events within the home.” from the report
No formal feedback system
needs fixingThe home was not formally seeking feedback from people, relatives, staff or professionals to help it improve.
“The service did not seek formal feedback from people, their relatives or other stakeholders to ensure they were continually learning and improving the service they provided.” from the report
- 01What changes have been made to make sure all risk assessments, fire checks and equipment checks are completed on time?
- 02What written guidance is now available for medicines people take occasionally, and how is staff practice checked?
- 03How are accidents and incidents now recorded, reviewed and used to prevent similar events?
- 04Who is responsible for each improvement action, and what deadlines and checks are in place?
- 05How are people, relatives, staff and professionals now being asked for formal feedback?
This was a focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings were carried over from previous comprehensive inspections. This explanation was written from the published report of 26 October 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 Clarendon House
3 rated inspections over 5 years: the service has held its Good rating throughout.
- January 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2021Requires improvementSafe: Requires improvementWell-led: Requires improvement
- March 2021Inspected but not ratedSafe: Inspected but not rated
- October 2017GoodSafe: GoodWell-led: Good
- July 2016
Registered with the Care Quality Commission on 21 July 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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