CQC report explained · a nursing home
What the CQC found at Clayton Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were generally considered safe and relatives praised staff's approaches. However, inspectors said individual risk management and the follow-up of lessons from incidents needed to be more robust.
- Effective?
- Good
- This question was not inspected during this focused visit. The previous rating was used in calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused visit. The previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused visit. The previous rating was used in calculating the overall rating.
- Well-led?
- Requires improvement
- Management checks, record-keeping and the implementation of lessons learned were inconsistent. The rating had deteriorated from Good at the previous comprehensive inspection.
What inspectors found, December 2019
Rated Good; inspectors found people felt safe, but records, risk follow-up and leadership needed improvement.
This was an unannounced focused inspection after concerns were raised about safety. The inspector visited only the unit for people living with advanced dementia. They spoke with seven people, four relatives and five staff, observed care and checked records.
The home was rated Good for Safe. People and relatives said people felt safe, staff were generally available, medicines records checked were accurate and the environment appeared clean. The home had added an evening shift after learning from incidents.
The home was rated Requires Improvement for Well-led. Inspectors found that risk management, record-keeping and checks on whether improvements were being followed were not always strong enough. They made recommendations but did not report a breach of regulations.
The overall rating remained Good because the other questions were not inspected during this focused visit and their previous ratings were used. The Well-led rating had fallen from Good to Requires Improvement.
People felt safe
People appeared relaxed around staff and relatives spoke positively about how staff kept family members safe, including during distress.
“I am well looked after here, although I do not really need much looking after.” from the report
Staffing changes
The home added an early evening shift after learning that people were at greater risk of falls. Agency use had also reduced, with regular agency workers used where possible.
“We do have a lot of agency, but we have regular agency staff who have been before. They know the residents.” from the report
Positive communication
Relatives said they were kept informed and described communication as improving when people's needs became more difficult.
“As things have got more difficult, communication just seems to improve.” from the report
Medicines checks
The electronic medicines system was being used effectively, and the medicine levels checked matched the records.
“Medication levels we checked matched those on records.” from the report
Risk plans were not always followed
needs fixingInspectors found that individual risk management strategies and actions from incidents were not always followed or recorded consistently.
“We recommend the service review their processes regarding risk management and lessons learned, to ensure assessments provide clear explanations and guidance, incident reports are completed, and consistency of approaches is ensured.” from the report
Records and quality checks
needs fixingSome important records were incomplete or unclear. Examples included a missing as-required medicines protocol and unclear reasons for the frequency of repositioning checks.
“Aspects of person-centred record-keeping needed to be improved.” from the report
Agency dementia training
needs fixingNot all agency worker information showed that staff had received the same dementia training. The manager followed this up with agencies.
“We highlighted that not all agency worker profiles stated that these staff had received equal training.” from the report
Duty of candour records
minorThe log used to show that the provider had met its legal duty to be open and honest after things went wrong needed updating.
“We discussed that this needed to be updated.” from the report
- 01What has been done to make sure each person's risk plan is followed consistently?
- 02How do you check that incidents are fully recorded and that lessons learned lead to lasting changes?
- 03Have all agency staff supporting people with dementia now completed the required training?
- 04Has the missing as-required medicines protocol been put in place and checked?
- 05What improvements have been made since the new registered manager took over?
This was an unannounced focused inspection of Safe and Well-led in the dementia unit only; the other ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 31 December 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, July 2019
Rated Good; inspectors found safe, kind care, but staffing pressure, shared thickener supplies and some care-plan gaps needed attention.
This was an unannounced inspection on 8 and 9 July 2019. Inspectors spoke with people living in the home, relatives, staff and healthcare professionals. They also observed care and checked care, medicine, staff and management records.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff to meet people's needs, safe medicines management, a clean home and kind care.
There were some areas to improve. Some staff reported staffing pressure and agency use. Individual thickener supplies were being shared communally, some care plans did not include enough personal detail, and oral health needs were not always recorded. There was also no registered manager during the inspection, although a new manager had been recruited and an interim manager was in place.
Safe care and medicines
Inspectors found that risks were assessed, equipment was checked and medicines were stored and given safely. Accidents and incidents were reviewed for lessons.
“There were enough numbers of staff to provide safe, consistent care that met the needs of the people living in the home.” from the report
Kind and respectful staff
People and relatives said staff were caring and knew them well. Inspectors saw that staff respected privacy, dignity and independence.
“People were treated with care, kindness and compassion. Feedback from people confirmed this.” from the report
Activities and relationships
People could take part in group or individual activities and were supported to stay in contact with relatives and other important people.
“People had access to a variety of activities and weekly bulletins told people what was on.” from the report
Checks and improvement
The home used audits, surveys and meetings to identify improvements. Inspectors found that identified actions were followed up.
“We saw where any improvements were identified that these were actioned in a timely manner.” from the report
Staffing pressure
needs fixingAlthough inspectors found enough staff at the time, some staff said staffing was not always sufficient and that agency staff were used. Recruitment was continuing.
“Some staff told us that there were not always enough staff, or agency staff were used.” from the report
Shared thickener supplies
needs fixingPeople's individual supplies of thickener were being shared communally. Inspectors raised this with the manager because it was not in line with good practice.
“However, we saw people's individual supplies were being shared on a communal basis not in line with good practice.” from the report
Care-plan detail
needs fixingSome care plans did not contain enough information about the person's history and preferences. The provider had already identified this and was reviewing the plans.
“We found some care plans were personalised and reflected the needs of the individual as well as their history and preferences. However, some plans were missing these details.” from the report
Oral health records
minorOral health needs were not always included in care plans. The manager agreed to review this as part of the wider care-plan review.
“Oral health care needs were not always identified within care plans.” from the report
Registered manager
minorThere was no registered manager when inspectors visited. A new manager had been recruited and an interim manager was running the home.
“There was no registered manager at the time of our inspection, however the post had been recruited to and an interim manager was covering the service.” from the report
- 01How many permanent staff are now in post, and how often are agency staff used on each unit?
- 02What action was taken to stop individual thickener supplies being shared communally?
- 03Have all care plans been checked so they include each person's history, preferences and oral health needs?
- 04Who is the registered manager now, and how was the change in management handled?
- 05What changes have been made to the menu following the mixed feedback about food?
This inspection was prompted in part by concerns about staffing and reviewed all five key questions, with each rating remaining Good. This explanation was written from the published report of 23 July 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 Clayton Manor
3 rated inspections over 2 years: the service has held its Good rating throughout.
- December 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2019Goodstayed GoodSafe: GoodWell-led: Good
- July 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2014
Registered with the Care Quality Commission on 13 November 2014.
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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