CQC report explained · a nursing home
What the CQC found at The Clavadel
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured that the home was preventing and managing infection risks, including through testing, personal protective equipment, social distancing, admissions procedures and hygiene.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, April 2021
Inspected but not rated; inspectors were assured about infection prevention and control during the COVID-19 pandemic.
This was an announced, targeted inspection on 12 March 2021. It looked only at infection prevention and control in response to the COVID-19 pandemic.
Inspectors were assured that the home managed visitors, testing, admissions, shielding, social distancing, personal protective equipment and hygiene safely. They also found that the infection prevention and control policy was up to date.
People continued to receive personal care and rehabilitation. Staff had regular COVID-19 training, and the home changed its layout and care pathways to reduce infection risks. The service was inspected but not rated, so this report does not give an overall quality rating.
Infection control arrangements
The home had care pathways covering testing, social distancing and self-isolation. Inspectors were assured that infection risks were being managed.
“People continued to access the vital personal care and rehabilitation services in a COVID-19 secure way throughout the pandemic and were complimentary about the support they received.” from the report
Staff training and support
Staff received regular infection prevention training, including checks of their practical skills. Their practice was also monitored through audits.
“Staff received a range of COVID-19 specific in house training which was refreshed every three months.” from the report
Adapted environment
The home changed its layout and equipment arrangements to support infection control and reduce unnecessary movement around the building.
“The service environment was reviewed and re-configured to ensure good IPC practice, zoning and cohorting and safety of the people receiving support as well as staff.” from the report
Visiting arrangements
The home provided both an outdoor visiting area and an indoor visiting area with direct access from the car park.
“There was a spacious garden available to people with a dedicated outdoor visiting area.” from the report
Inspectors raised no specific concerns in this report.
- 01How are people tested and supported when they first arrive at the home?
- 02How often is staff infection prevention training refreshed now, and how is practical competence checked?
- 03How are personal protective equipment use and handwashing monitored?
- 04How are the hydrotherapy facilities currently risk assessed and kept safe?
- 05What visiting arrangements are currently available, and how are visitors protected from infection?
This was a targeted inspection of infection prevention and control under Safe only; the service was inspected but not rated and the other areas were not assessed. This explanation was written from the published report of 1 April 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, October 2017
Rated Good; inspectors found safe, kind and effective care, and said earlier problems with recruitment, records and checks had been addressed.
This was an unannounced follow-up inspection on 29 September 2017. Inspectors spoke with seven people, the registered manager and four care staff. They reviewed five care plans, risk assessments, medicines and incident records, complaints, audits and eight recruitment files.
The home provides short-term rehabilitation and recovery care, including physiotherapy and hydrotherapy. Inspectors found enough staff, safe medicines arrangements, suitable recruitment checks and a clean, well-maintained environment. People said staff were kind, respectful and supportive of their independence.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. The inspection followed three breaches found in August 2016. Inspectors said action had been taken and those earlier concerns had been addressed.
Rehabilitation support
People received support aimed at improving their health and mobility. The home had in-house physiotherapy and hydrotherapy, as well as access to other health professionals.
“People were supported to regain their health and mobility.” from the report
Kind and respectful care
Inspectors saw staff respecting privacy, explaining care and supporting people to make their own choices.
“Staff always knock on my door before coming in.” from the report
Staffing and safety
Inspectors found enough staff to meet people's needs. Staff understood individual risks and acted to reduce the chance of accidents or harm.
“There were enough staff to meet people's needs and appropriate checks were carried out to help ensure only suitable staff worked at the service.” from the report
Improved oversight
Regular audits were in place and feedback from people led to changes, including bathroom improvements.
“Quality assurance audits took place to help ensure a good, safe quality of care was being provided to people.” from the report
Past medicines recording gaps
minorMedicines audits had previously found some gaps in records. Inspectors said these had been addressed, but families may wish to ask how records are checked now.
“We noted in the past these had identified some gaps in medicines records and saw that the matron had addressed these shortfalls with staff.” from the report
- 01What physiotherapy and hydrotherapy would be offered for this person's condition, and how would their rehabilitation goals be reviewed?
- 02How are medicines records checked now, following the gaps identified in earlier audits?
- 03What activities and social opportunities would be available during a short stay, given that there are no dedicated in-house activities?
- 04How would the care plan be updated if the person's mobility, nutrition, medication or emotional needs changed?
- 05How would we raise a complaint, and how would we be kept informed of the response?
This was an announced follow-up inspection covering all five quality areas, checking action taken after concerns found at the August 2016 inspection. This explanation was written from the published report of 17 October 2017 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 The Clavadel
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- April 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- October 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2014
Registered with the Care Quality Commission on 14 April 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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77 live-in carers within about an hour of Surrey
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,250 a week. 66 can care for a couple. 11 years' experience on average.
“Without his support we wouldn't have been able to navigate bringing and keeping Dad at home.”
“Not only has she looked after him beautifully, she has also been great company for him with lively conversation, kindness and humour.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.