CQC report explained · a residential care home
What the CQC found at Clarendon Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm and staff understood how to manage risks. Some catheter care plans needed more detail, one safeguarding incident had not been referred promptly, and the home relied heavily on agency staff.
- Effective?
- Good
- This area was not inspected during this visit. Its previous rating was carried forward.
- Caring?
- Good
- This area was not inspected during this visit. Its previous rating was carried forward.
- Responsive?
- Good
- This area was not inspected during this visit. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- Management was described as approachable and supportive, but audits and records did not always identify or clearly show risks. Two incidents had not been reported to CQC when they should have been.
What inspectors found, April 2022
Clarendon Manor was rated Good overall, but inspectors found that management and quality checks needed improvement.
This was an unannounced, focused inspection after concerns about infection control and safeguarding. Inspectors visited on 24 March 2022, spoke with people, staff and relatives, and checked care records, medicine records and management records.
The home was rated Good for Safe. Inspectors found that staff understood risks, medicines were given as prescribed, and people were protected from abuse and avoidable harm. However, some catheter care plans lacked detail, some safeguarding records were unclear, and the home relied heavily on agency staff.
The home was rated Requires Improvement for Well-led, down from Good at the previous inspection. Quality checks did not always identify problems, including incorrect pressure mattress settings and incomplete catheter monitoring records. The manager introduced a stronger mattress checking system during the inspection and planned further audits.
The overall rating stayed Good because the other three areas were not inspected and their previous ratings were carried forward. CQC said it would continue to monitor information about the home.
Staff understood safety risks
Staff knew how to reduce risks such as falls and understood their safeguarding responsibilities. Equipment such as sensor mats, bed rails and call bells was in place when needed.
“Staff understood their role in risk management and monitored people and their environment to keep them safe.” from the report
Medicines were given safely
The medicine records checked showed that people received their medicines as prescribed. Staff also recorded why and when as-required medicines were given and their outcome.
“Medicine administration records we reviewed showed people had received their medicines as prescribed.” from the report
Kind and reassuring care
Relatives gave positive feedback about the care and said they felt their family members were safe and well looked after.
“Relatives told us they felt their loved ones were well looked after and received safe care from staff who were kind, caring and proactive.” from the report
Supportive management and teamwork
Staff and relatives described managers as approachable. Staff said they worked well together and that the home had a friendly atmosphere.
“Feedback from people, their relatives and staff about the management of the home was positive and management were described as approachable and supportive.” from the report
Incomplete risk and care records
needs fixingSome catheter care plans did not contain enough detail. Fluid intake and output records were also not consistently completed, which could make it harder to spot infection risks.
“Records were not always completed accurately or clearly to demonstrate safe practice and enable effective monitoring to take place.” from the report
Quality checks were not reliable enough
needs fixingSome pressure mattresses were on the wrong setting, and there were no audits to identify patterns in falls, accidents or injuries. A stronger mattress audit was introduced during the inspection.
“However, we identified a number of mattresses that were not on the correct setting.” from the report
Heavy use of agency staff
needs fixingStaff vacancies meant many shifts were covered by agency workers. Two agency workers on the inspection day were new to the home and did not always support the permanent team effectively.
“This had potential to impact on the standard and timeliness of the support people received.” from the report
Reporting was not always completed
needs fixingTwo incidents had not been reported to CQC and one safeguarding incident had not been referred to the local authority. These were reported after the inspection.
“Overall, CQC were notified of important events and incidents as per regulations. However, we found two incidents had not been referred to us.” from the report
PPE was not always worn correctly
minorStaff had training in using PPE, but inspectors saw some face masks being worn below the nose or chin.
“However, staff were observed wearing face masks below the nose and chin which does not follow guidelines.” from the report
- 01How are catheter care plans and fluid intake and output records now checked for completeness?
- 02How often are pressure-relieving mattresses checked, and how do you make sure they are set correctly?
- 03What has changed in the process for auditing falls, accidents and injuries?
- 04How are agency staff shown the home's routines before they provide care, and how is their work monitored?
- 05What steps ensure safeguarding incidents and other important events are reported to the right authorities promptly?
This was a focused, targeted inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings were carried forward from the previous inspection. This explanation was written from the published report of 28 April 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, March 2019
Rated Good; inspectors found safe, kind and personalised care, with improvements since the previous Requires Improvement rating.
Inspectors visited unannounced on 12 March 2019. They spoke with people living in the home, a relative and staff. They also reviewed care, medicine and staff records, and checked how the home was managed.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicine practices, well-managed risks and staff who understood people's needs and preferences.
The home had improved since the previous inspection. Safety checks, maintenance, activities, medicines management and quality monitoring had been strengthened. Inspectors still noted some smaller issues, including inconsistent recording of accidents and falls.
Safer care
Risks to people's health and wellbeing were assessed and managed. Safety improvements had been made to the building and equipment.
“Risks to people's health and well-being were assessed and well managed.” from the report
Safe medicines
Medicines were stored, given and recorded safely. Staff stayed with people until they had taken their medicines.
“People's medicines were managed safely and in line with best practice guidelines.” from the report
Kind and respectful staff
People appeared relaxed and were supported with dignity, choice and independence. Staff spent time talking with people about their interests.
“There was a friendly atmosphere in the home and people appeared relaxed in their surroundings.” from the report
Personalised support
Care plans included people's physical, emotional, social and personal preferences. Staff knew people well and responded to their individual needs.
“People received personalised care that was responsive to their individual needs.” from the report
Improved activities
People had more opportunities to take part in group and individual activities, including exercise, games and creative work.
“The registered manager had improved the opportunities for people to engage in group activities with regular exercise classes, bingo and a weekly creative art group facilitated by an external provider.” from the report
Accident records were not always consistent
needs fixingStaff did not always record accidents and falls in line with the home's policy. The manager said staff would be reminded of the correct approach.
“However, we found staff were not always consistent in how they recorded accidents and falls in line with the provider's policy.” from the report
Communication standard not known to manager
minorThe manager was not aware of the Accessible Information Standard. Inspectors nevertheless found that people's sensory and communication needs had been assessed and supported.
“The manager was not aware of AIS. However, we saw from care plans that people's sensory and communication needs had been assessed and were being supported.” from the report
Staff sometimes entered rooms too quickly
minorStaff knocked on bedroom doors but sometimes entered before waiting to be invited in. People and professionals still described staff as respectful.
“Staff respected people's individual privacy in the home, by knocking on people's doors, although sometimes they did not wait to be invited in before entering the room.” from the report
- 01How do you make sure accidents and falls are recorded consistently and reviewed for any patterns?
- 02How do you support residents' sensory and communication needs, including for people who cannot communicate verbally?
- 03What checks are now used to maintain the improvements made after the previous inspection?
- 04How do you make sure staff respect privacy by waiting before entering bedrooms?
- 05What activities are currently available, and how are residents' individual interests and choices included?
This was an unannounced scheduled inspection covering all five CQC questions and both the premises and the care provided. This explanation was written from the published report of 23 March 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 Manor
4 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- April 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- March 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2017Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2016
Registered with the Care Quality Commission on 22 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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