CQC report explained · a residential care home
What the CQC found at Clipstone Hall & Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2022
Rated Requires Improvement; inspectors found major progress since the previous inadequate rating, but medicines records and quality checks still needed strengthening.
This was an unannounced follow-up inspection. Inspectors visited the home on 6 September 2022 and spoke with people, relatives, staff and health professionals. They reviewed care plans, medicines records, staff recruitment files and management records.
The home had improved from an overall Inadequate rating. Safe, Effective, Caring, Responsive and Well-led were all assessed. Effective, Caring and Responsive were rated Good. Safe and Well-led were rated Requires Improvement.
Medicines were being given safely, but there were gaps in controlled-drug stock records and some missing paperwork for prescribed medicines. The manager acted during the inspection. Audits had not found these problems, so the home needed to make its checks more reliable.
The home had improved enough that it was no longer in breach of regulations and was no longer in Special Measures. However, there was still no registered manager in post, although a new manager had started the registration process.
Kind and respectful staff
People and relatives consistently praised staff for their kindness, compassion and support. People said their dignity, privacy and independence were respected.
“All people we spoke with, including family and loved ones told us that staff treated them with kindness and compassion.” from the report
Improved staffing and training
Inspectors found safe recruitment, enough competent staff and better training since the previous inspection. People also said they no longer had to wait as long for help.
“Staff were recruited safely and there were always enough competent staff on duty.” from the report
Personalised care planning
Care plans had been reviewed and rewritten. They recorded people's choices, needs, risks and wishes, including arrangements for end-of-life care.
“Care was assessed, planned and delivered in a person-centred way.” from the report
People and families involved
People and relatives were included in care reviews and could give feedback through meetings, one-to-one discussions and other routes.
“The manager had implemented a variety of ways for people to express their views including resident meetings, one to one meetings and applications for advocates” from the report
Better partnership working
Staff worked with health and social care professionals and acted on advice. Professionals said the home was identifying concerns earlier and seeking help more quickly.
“Staff are identifying issues earlier and requesting support, this is preventing people developing serious conditions and infections” from the report
Medicines records
needs fixingInspectors found gaps in controlled-drug stock records and missing prescriptions for some as-required medicines. The manager corrected or began correcting these issues during the inspection.
“Improvements had been made in administering medicines safely to people, however we identified gaps in the recording of medicines stock levels.” from the report
Quality checks missed problems
needs fixingThe home's audits had not identified the medicines issues found by inspectors. More time was needed to make the audits thorough and reliable.
“These had failed to identify the issues we found with medicines.” from the report
No registered manager
needs fixingThere had been no registered manager since January 2022, despite this being a condition of the home's registration. A new manager had started the registration process.
“The provider has not had a registered manager in place since January 2022 as per the condition of their registration” from the report
Some infection control practice
minorStaff used PPE appropriately, but disposal of PPE was not always in line with best practice guidance.
“Staff were trained and wore PPE appropriately however the disposal of PPE was not always in line with best practice guidance.” from the report
Incomplete emergency care forms
needs fixingSome ReSPECT forms were not fully completed or written in a person-centred way. The manager had started work with the local GP practice to update them.
“Where people had recommended summary plan for emergency care and treatment (ReSPECT) forms in place, the manager acknowledged these were not always completed fully or in a person-centred way.” from the report
- 01How do you now check controlled-drug stock levels and make sure all prescribed-medicine paperwork is present?
- 02How often are medicines audits completed, and how do you make sure they identify problems promptly?
- 03When will the manager's registration process be completed, and who is legally responsible for the home until then?
- 04Have all ReSPECT forms been reviewed with people, families and health professionals so they reflect each person's wishes?
- 05How is PPE disposal checked to make sure it follows current best practice guidance?
This was an unannounced follow-up inspection after the previous Inadequate rating, with a home visit on 6 September and relative telephone calls on 8 September; inspectors assessed all five key questions. This explanation was written from the published report of 14 October 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, May 2022
Rated Inadequate and placed in special measures; inspectors found serious problems with safety, medicines, staffing and management.
This was an unannounced inspection on 06 April 2022 and 08 April 2022. Inspectors spoke with people living at the home, relatives, staff and other professionals. They also checked care records, medicine records, staff files and management records.
The home was not safe. Inspectors found poor infection control, dirty equipment and unsafe medicine practices. Staffing levels and training did not always meet people's needs. Care plans were often incomplete or out of date.
The home received Requires Improvement for Effective, Caring and Responsive. It received Inadequate for Safe and Well-led, giving an overall rating of Inadequate. The previous rating was Good under the previous provider, published on 1 August 2019.
The home was placed in special measures. The CQC said it would request an action plan, monitor progress and usually re-inspect within six months if it did not propose cancelling the provider's registration.
People felt safe
People and relatives told inspectors they felt safe at the home. Staff understood how to recognise and report abuse.
“People and relatives told us they felt safe within the home.” from the report
Kind staff
People and relatives said staff were caring and supportive, although staff also felt rushed and unable to spend enough time with everyone.
“People said that although staff were rushed they were treated well.” from the report
Food choices
People were offered choices about meals and drinks. Inspectors saw people being encouraged to decide what they wanted.
“We observed people being offered choice and encouraged to make decisions about what they wanted to eat and drink.” from the report
Safe recruitment
The home carried out recruitment checks, including references and DBS checks.
“Pre-employment checks, such as seeking references and DBS checks, were carried out.” from the report
Consent arrangements
Inspectors found that consent was sought in line with legal requirements and that applications had been made where restrictions needed authorisation.
“Consent to care was sought in line with legislation and guidance.” from the report
Unsafe medicines
seriousMedicines were not always given safely or on time. Records and guidance were incomplete, and mistakes were repeated.
“People did not receive their medicines in a safe or timely manner.” from the report
Poor infection control
seriousCommunal areas, equipment and aids were not consistently clean or safe. Staff were unclear about cleaning responsibilities and food hygiene was not always followed.
“The service did not follow or meet national guidance in relation to infection control which placed people at risk of infection.” from the report
Staffing and training gaps
seriousPeople sometimes waited too long for support. Staff deployment did not reflect care needs, and training records showed important gaps.
“Staff deployment meant people's needs were not met in a timely manner.” from the report
Incomplete care plans
seriousCare plans did not always describe people's current needs, risks, preferences or the support staff should provide. This included health needs and end of life wishes.
“People's care plans were not always personalised to ensure their needs were met.” from the report
Weak management oversight
seriousAudits and checks did not reliably identify or fix problems. Known issues were repeated, and there was no registered manager in post.
“The provider failed to ensure the quality, safety and leadership of the service.” from the report
Limited activities and communication
needs fixingActivities were inconsistent and some people waited for help to take part. People and relatives said they were not always kept informed or asked for feedback.
“We observed one person waiting for over an hour after asking staff for assistance to undertake an activity.” from the report
- 01What changes have been made to ensure medicines are given safely, on time and in line with manufacturers' guidance?
- 02How are cleaning responsibilities, equipment checks and food hygiene now monitored?
- 03How many staff are on each shift, and how do you match staffing to people's actual care needs?
- 04Have all residents' care plans and risk assessments been reviewed and updated, including end of life wishes and communication needs?
- 05Is there now a registered manager, and how are audits and action plans checked to make sure problems do not happen again?
This was the first inspection of the newly registered service and covered all five key questions, including infection prevention and control; there was no registered manager in post at the time. This explanation was written from the published report of 17 May 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.
Every inspection of Clipstone Hall & Lodge
4 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- October 2022Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2022InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- April 2021Inspected but not ratedSafe: Inspected but not rated
- August 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2018Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2020
Registered with the Care Quality Commission on 6 February 2020.
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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