Claremont Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last inspection we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The service did not have an effective quality assurance system which meant that shortfalls were not always identified or addressed promptly. Issues were identified at the last inspection and while some improvements have been made, the provider remains in breach of the regulations in relation to good governance.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Staff told us they were happy working at the service; however, staff and relatives comments included a need for a consistent manager. There was a positive culture at the service, we observed person-centred culture in the service. Staff we spoke with understood and supported the values and vision of the organisation.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. There had not always been effective management of the service. Feedback from staff was mixed as there had been a high turnover of managers and they felt there had been a lack of consistency from the management team. At the time of our assessment, there was not a registered manager in post.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff were knowledgeable on the procedure they needed to follow to raise concerns. One staff member said, “If there was a safeguarding concern I would report it straight to the manager, if not I would report to CQC or the police depending on the circumstances.” A whistleblowing policy was in place. Policies were available to staff and staff knew where to find them. Staff appraisals and supervisions demonstrated that staff had the opportunity to raise issues.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff told us they felt supported. Staff were required to complete a health questionnaire during the recruitment process to support any adjustments if needed in relation to their role. The provider had systems in place to support a robust recruitment process.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider was not always able to identify short falls in the service. The high turnover of managers led to inconsistencies and poor oversight of system performance. Systems that were in place were not always effective therefore this did not mitigate risks for people. The provider’s systems for monitoring and mitigating risk had not identified shortfalls in medicines management, safeguarding and consent, as well as environmental issues we found on inspection.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. Systems in place to implement learning from quality visits were not always sufficient to ensure actions were taken proactively and learning shared in a timely manner. The use of questionnaires and surveys was not well developed with staff or external agencies. However, staff worked in partnership with external professionals to help make sure people’s needs were assessed, monitored and met.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. Whilst improvements had been made, the provider remained in breach of legal regulations. This indicated that systems for learning and improving the service had not always been effectively implemented. The new manager had started to address areas which they felt could improve.