CQC report explained · a residential care home
What the CQC found at Clarendon Mews Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found risk assessments, choking guidance, staff training, safeguarding processes and medicines practice had improved. They noted that protocols for some as-required medicines were not fully in place during the inspection, but these were put in place afterwards.
- Effective?
- Good
- This question was not looked at during this focused inspection. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- People were treated with dignity and respect, involved in care decisions and supported to remain as independent as possible. Inspectors saw positive interactions and relatives praised the staff team's caring attitude.
- Responsive?
- Good
- This question was not looked at during this focused inspection. Its previous rating was used in calculating the overall rating.
- Well-led?
- Requires improvement
- The home had improved its governance systems and action plan, but records still had gaps. Some required night checks, repositioning records and fluid monitoring were not consistently recorded.
What inspectors found, August 2021
Rated Good and no longer in special measures; inspectors found safe, caring support but weak monitoring and leadership that still required improvement.
This was an unannounced focused inspection on 28 July 2021. Inspectors spoke with people living in the home, relatives and staff. They reviewed care records, medicines records, recruitment files, training information and management records.
The home had improved since its previous Inadequate rating. Safe and Caring were rated Good. Inspectors found better safeguarding, staff training, incident reviews, medicines practice and person-centred care.
Well-led was rated Requires Improvement. Some records did not show that planned night checks, repositioning or fluid monitoring had taken place. The home had improved its systems and was working on a further action plan, but monitoring was not yet reliable.
The home was previously in special measures and had conditions placed on its registration. Inspectors found it was no longer in breach of regulations and was no longer in special measures. The overall rating changed from Inadequate to Good, although some ratings were carried forward from the earlier comprehensive inspection.
Improved safety
The home had improved how it identified risks, investigated incidents and protected people from abuse or improper treatment.
“Incidents of safeguarding and serious injuries had significantly reduced.” from the report
Choking risk support
People at risk of choking had clear care instructions. Staff had specialist training and inspectors saw people being supported sensitively at mealtimes.
“All staff involved with supporting people to eat and drink had received specialist training on Dysphagia (choking risks).” from the report
Kind and respectful care
Inspectors saw staff treating people with dignity, offering choices and supporting independence. Relatives were positive about the care provided.
“Throughout the inspection we saw positive interactions between staff and the people using in the service.” from the report
Better staff training
Staff had received refresher training in areas including positive behaviour support, swallowing difficulties and medicines management.
“The training in positive behaviour support had significantly reduced the number of incidents of physical altercations between people living at the service and aggressive incidents towards staff.” from the report
Improved openness
The provider had improved its reporting to the CQC and safeguarding authorities and had discussed incidents with people and relatives.
“The provider had been open and honest when things went wrong.” from the report
Gaps in care monitoring
needs fixingSome records did not show that planned night checks, repositioning and fluid monitoring had been completed. The provider said its systems would be strengthened to identify gaps more quickly.
“We found gaps in monitoring records where staff had not recorded observations as required in the individual care plans and risk assessments.” from the report
Management oversight
needs fixingThe Well-led rating remained Requires Improvement because leadership and monitoring were not yet consistent. At the time of inspection, the home did not have a manager registered with the CQC, although applications were in progress.
“This meant the service management and leadership was inconsistent.” from the report
Communication with some relatives
minorSome relatives said communication from the home had reduced recently, although they expected to be contacted in an emergency.
“Some relatives commented that more recently communications from the home had lessened, although they felt sure they would be contacted in an emergency.” from the report
- 01How do you now check that night checks, repositioning and fluid monitoring are completed and recorded without gaps?
- 02What action will you take if a care monitoring record is incomplete?
- 03Has a manager now been registered with the CQC, and who is currently responsible for the home's day-to-day leadership?
- 04How are as-required medicines checked and recorded for each person?
- 05How will you keep relatives updated about their family member's health, welfare and care?
This was a planned focused inspection of Safe, Caring and Well-led; Effective and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 21 August 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.
What inspectors found, January 2021
Rated Inadequate and placed in special measures; inspectors found serious risks involving safety, medicines, safeguarding and management.
This was an unannounced inspection on 25 September and 1 October 2020. It began as a targeted inspection about eating support and choking risks, then widened to look at Safe, Caring and Well-led.
Inspectors found widespread problems. People were not always protected from harm, medicines were not always given or stored safely, care records and risk assessments were out of date, and some people experienced physical and emotional harm. Staff had not received all the specialist training needed.
The home was rated Inadequate overall. Safe and Well-led were Inadequate, and Caring Requires Improvement. Effective and Responsive were not rated in this inspection, so this report does not give a current rating for those areas.
After the inspection, the provider said it had stopped unnecessary physical intervention, arranged de-escalation training, accepted specialist medicines support and engaged a consultancy firm. The home was placed in special measures and CQC said it would usually re-inspect within six months.
Some kind interactions
Inspectors saw positive interactions between staff and people. Staff generally spoke warmly about the people they cared for.
“Throughout the inspection we saw positive interactions between staff and the people living in the service.” from the report
Contact with relatives
During the pandemic, the home supported people to keep in touch with relatives through video calls, telephone calls and regular updates.
“Since restrictions commenced the service facilitated video calls with family members along with telephone calls and regular updates.” from the report
Partnership working
The home worked with health professionals involved in people's care, including doctors, community nurses and other professionals.
“The service worked in partnership with other health professionals involved in people's care.” from the report
Some safety improvements
Inspectors found that maintenance and health and safety were being monitored effectively. The provider also corrected some mealtime and infection-control issues during or after the inspection.
“The providers had an effective system in place to monitor maintenance and health and safety aspects of the service.” from the report
Physical intervention and safeguarding
seriousRecords showed that some people were routinely held by their arms and legs during personal care. Incidents, injuries and allegations were not properly investigated or reported, increasing the risk of repeated harm.
“This included being held by their arms and legs during personal care tasks.” from the report
Medicines and choking risks
seriousThere were unexplained gaps in medicine records, inaccurate handwritten charts and unsafe storage. Some choking risk assessments and diet information were missing or out of date.
“People did not always receive their medicines as prescribed and there were unexplained gaps on medicine administration charts (MAR).” from the report
Out-of-date care records
seriousCare plans and risk assessments did not always reflect people's current needs. This included risks linked to eating, moving and handling, skin care, mental health and distressed behaviour.
“Care plans and risk assessments were not updated when people's needs changed.” from the report
Insufficient specialist training
seriousStaff had not received all the specialist training needed to support people with distressed behaviours, advanced dementia, complex mental health needs and dysphagia.
“The provider had not ensured people received care from staff who were suitably qualified, skilled or competent.” from the report
Dignity and involvement
needs fixingInspectors saw a person left waiting for help to eat, confidential medicine information visible in a communal area, and limited evidence that people or relatives helped agree and review care plans.
“The provider failed to treat people with dignity and respect at all times.” from the report
- 01What evidence can you show that medicines are now given as prescribed, recorded accurately and stored at the correct temperature?
- 02How are choking risks, diet changes and dysphagia support recorded and checked for each person?
- 03What rules and training now prevent unnecessary physical restraint, and how are any incidents investigated and reported?
- 04How do managers check that care plans and risk assessments are up to date and reflect people's current needs?
- 05What conditions did CQC impose on the registration, and what improvements have been completed since this inspection?
This began as a targeted inspection of eating support and choking risks, then became a focused inspection of Safe, Caring and Well-led; Effective and Responsive were not rated and the other ratings were not carried out in this inspection. This explanation was written from the published report of 8 January 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 Mews Care Home
3 rated inspections over 4 years: the service has held its Good rating throughout.
- August 2021Goodcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2021Inadequatedown from GoodSafe: InadequateCaring: Requires improvementWell-led: Inadequate
- September 2017GoodSafe: GoodCaring: OutstandingWell-led: Good
- July 2016
Registered with the Care Quality Commission on 20 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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