Clarence House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. People were supported by a culture of openness and transparency which was evident at Clarence House. Staff understood the importance of reporting incidents and accidents immediately and accurately. They felt confident to raise concerns, supported by the registered manager who had clear processes to review and reduce risks. Accidents, incidents, and significant events were recorded on the provider’s electronic governance system. The registered manager was informed of each incident and undertook regular audits to identify trends and inform improvements. Safety incidents were reported, investigated, and used to drive learning and enhance service quality. Staff described a positive working environment where training, supervision, and reflective practice were valued. They felt supported by leadership and encouraged to contribute ideas for improvement. Feedback from partner organisations confirmed effective collaboration and communication with the service. Partners highlighted the service’s responsiveness and commitment to continuous improvement, which contributed to better outcomes for people using the service. Relatives confirmed they were kept informed of significant changes or events. A relative said, “They will always phone me. I know that my loved one is well looked after.”

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.People felt confident their needs would be met by staff and that important information would be shared to ensure continuity of care. Staff told us they had access to relevant information when working with external professionals, including when a person was admitted to hospital or transferred to another care service. Care plans and risk assessments were detailed and maintained on the provider’s electronic system, ensuring staff had up-to-date guidance on people’s needs. A summary sheet accompanied people if they went into hospital or moved to a new care home, supporting smooth transitions and continuity of care. Feedback from staff and leaders confirmed that effective communication pathways were in place to manage transitions safely. Partner organisations told us about the service’s proactive approach to sharing information and collaborating to meet people’s changing needs.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.People told us they felt happy, content, and safe living at the service. A person said, “I love it here, it’s homely and everyone is nice.” We observed staff working together in safe ways. Staff demonstrated a comprehensive understanding of how to protect people from avoidable harm. They described how they would raise concerns both within the service and with external agencies. Staff expressed confidence the registered manager would address any concerns promptly. A staff member said, “The registered manager is wonderful and approachable, you raise any concerns, it doesn’t matter how big or small [name] will address it.” Staff had received safeguarding adults training with regular updates and knew how to ensure people’s rights were respected. The registered manager maintained a safeguarding log that detailed each incident and the actions taken. Records confirmed that safeguarding referrals had been made to the local authority, along with statutory notifications to CQC as required by law. Legal applications had been made in accordance with the Deprivation of Liberty Safeguards (DoLS), ensuring people’s rights were protected. The registered manager-maintained oversight of DoLS applications, authorisations, and conditions, using a tracker to ensure all documentation remained current.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.People were involved in managing risks to their health, safety, and wellbeing in ways that promoted their independence and respected their preferences. Risk assessments were in place for all aspects of people’s care and support needs. The provider used an electronic care planning system, which allowed updates to be made instantly, ensuring staff had access to the most current information about people’s risks. Staff told us they were committed to supporting people safely, and assessments were detailed and personalised. We observed people being supported to eat and drink in a respectful way in line with their risk assessments. General risk assessments were also in place to address people’s needs within the communal environment. Staff demonstrated a thorough understanding of these assessments and showed dedication to supporting people in a safe way.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.People and their relatives were complimentary about the service, describing it as homely and hygienic. Equipment and facilities were safe, clean, and well-maintained. We observed the environment to be clear and free from obvious hazards. The registered manager demonstrated a clear understanding of their responsibilities to maintain a safe environment and described the measures in place to manage safety.Potential environmental risks were identified and effectively controlled. The service ensured that equipment, facilities, and technology supported safe care delivery. External specialists and contractors carried out essential safety checks, including gas and fire safety. Each person had a personal emergency evacuation plan, and the fire alarm system was tested weekly to ensure ongoing safety.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Recruitment procedures were in place to ensure all necessary checks were completed before staff commenced employment. This included enhanced Disclosure and Barring Service (DBS) checks for adults. DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions. During the inspection, we observed enough staff on duty to meet people’s needs safely. Feedback from people and their relative’s confirmed staff were available when needed. A relative said, “Staff are the most caring. I can’t fault them.” We observed natural and warm interactions between staff and people, demonstrating staff knew people well. People remained alert and engaged throughout the day, and the atmosphere was calm. Training was relevant to staff roles and ongoing, supported by regular supervision and appraisal processes to maintain safe and effective support. Staff reported they received enough training to perform their duties confidently. The registered manager-maintained oversight of training within the service.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.Staff received training in infection prevention and control, ensuring they were equipped with up-to-date knowledge. A dedicated team-maintained cleanliness throughout the service, working to agreed schedules. We observed the service to be hygienic and well maintained, featuring a spacious, bright lounge area with access to a well-kept garden. This was positively remarked upon by people using the service and their relatives. Staff wore personal protective equipment (PPE), and safe infection prevention and control procedures underpinned daily practice. Infection control procedures and audits were carried out in line with good practice guidance. Staff had plentiful supplies of cleaning materials, products, and PPE. Clarence House received external recognition in 2024, winning the “Best Domestic Team” award from a care organisation, highlighting the high quality of cleaning and infection control standards maintained.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. People received their medicines safely and as prescribed. For medicines taken ‘when required,’ personalised guidance was in place to help staff determine when these should be administered. Individual risks were carefully considered, particularly for higher-risk medicines such as blood thinners and flammable preparations. The service maintained suitable arrangements for ordering, storing, and disposing of medicines, including those requiring cold storage and additional security measures. Temperature monitoring was regularly conducted to ensure medicines remained safe and effective. Staff received appropriate training, and competency checks to administer medicines safely. Regular medicines audits were undertaken, and any incidents were reported, investigated, and used to inform actions to prevent recurrence. However, for medicines requiring frequent monitoring and dose adjustments, written confirmation of instructions was not always received by the service promptly. During the inspection, new procedures and an updated policy were introduced to ensure robust processes for managing verbal instructions while awaiting written confirmation. We were fully assured by the measures taken.