Archived: Clarendon Gardens

Updated 13 May 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by 1 inspector and an inspection manager.

Service and service type

Clarendon Gardens is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Clarendon Gardens is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post, however they were not there on the day of the inspection.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 20 February 2023 and ended on 1 March 2023.

What we did before the inspection

We reviewed information we had received about the service since our last inspection, which included notifications which the provider must send to us of significant events. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

During the site visit we met and spoke with the registered provider, 2 support workers and 2 people who lived at the service. We could not speak to the registered manager as they were away from the service at the time of the inspection. We spoke with the nominated individual on the phone. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We viewed a range of records. We looked at care records for 4 people. We also looked at 6 staff files in relation to recruitment, training and support.

Updated 13 May 2023

About the service

Clarendon Gardens is a care home providing accommodation for persons who require nursing or personal care to up to 6 people. The service provides support to people who live with mental health conditions. At the time of our inspection there were 4 people living in the home.

People’s experience of using this service and what we found

The service was experiencing a staffing crisis. There were insufficient staff available to work including at manager and care worker level. The provider had not taken action to address this and the safeguards we found in place were inadequate.

The service did not follow safe recruitment procedures and staff were not sufficiently vetted to ensure they were suitable to support people who used the service. Staff lacked essential training and training records were not kept. Medicines were not always managed safely. Building and environmental checks were either out of date or non-existent.

Overall, the quality assurance monitoring system was not effective to ensure appropriate improvements were made to care for people who used the service. Risks to people were not always adequately assessed. The provider did not have effective systems in place to review care plans and risk assessments.

There were systems in place to protect against the spread of infection.

Staff worked with healthcare and social care professionals, to ensure people had a safe and effective service.

Staff were aware of their responsibilities to report allegations of abuse. People told us they felt safe using the service

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People made decisions about their care, and about matters to do with the running of the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 7 April 2021).

Why we inspected

We received concerns in relation to the lack of staff training, staffing levels and the provider managing the home without sufficient knowledge of people’s needs. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

The overall rating for the service has changed from good to inadequate based on the findings of this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, staff recruitment, person centred care and good governance at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.