Clarendon House Care Home

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.

This is the first assessment for this service since registration. This key question has been rated Good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Systems were in place to ensure staff were aware of their roles and responsibilities to report incidents and accidents. Staff told us they knew how to report concerns about people’s safety. They felt able to raise concerns with the registered manager and felt they would be listened to, and action taken. Daily meetings were held with the registered manager or person in charge, these were used as opportunities to share any learning points to prevent harm to people. In addition, occasional, group supervision meetings were held with staff where accidents and incidents were discussed to share learning.

The provider 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 who required hospital admission were supported by staff to ensure the transfer happened smoothly. One person told us, “The first carer established it was more than a sprain then 3 senior staff checked on me swiftly and I was taken to hospital.”

Several people had moved to the home after falls; relatives told us assessments were carried out promptly so people could move safely from hospital to Clarendon House.

A visitor told us about their friends who were living at the service after both were discharged from hospital. They told us although one initially moved in before the other, they were moved to adjacent rooms as soon as possible, and had described the process of moving in as a “smooth one”. They told us, “Their needs are very different, though both have their needs met by the service”, “I know they are perfectly safe here, it’s a home from home” and “When our [person] moved in just before Christmas, the service captured their life history. Father Christmas was able to mention this during their interaction at the [Christmas] party”. We all felt welcomed because of this”.

External healthcare partners told us how the service worked well with them to support their visits to Clarendon House. They said communication was good and it was clear what they were required to do each visit. Staff stayed with people to share information as required. One healthcare professional told us, “Staff collaborate well, and there are always staff around to speak to and this information is shared with relatives”.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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 provider shared concerns quickly and appropriately.

People told us they felt safe living at Clarendon House. People told us, “Safe, yes I feel safe, you only have to have a minor emergency and things happen very quickly”, “Very much, I do feel safe here, yes, because nothing has gone wrong” and “Yes I do feel safe, yes because people come to see me and there are people around all the time”.

Staff told us they had received training on how to recognise abuse and had confidence to report any safeguarding concerns to the registered manager. We noted where safeguarding concerns had been reported to the local authority, the service worked in collaboration with them to ensure risk of harm was minimised.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The provider was aware of their responsibilities to apply to the supervisory body (local authority) when a person was not able to consent to live at Clarendon House and were not safe and free to leave. There were systems in place to monitor applications made.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were kept safe and the likelihood of injury or harm was reduced. We found written risk assessments were in place to assess likely hazards and how these could be reduced. For example, where people were helped to reposition, appropriate measures were put in place to minimise the risk of skin pressure damage. When required, two staff assisted people who required lifting equipment to help them move.

Where the service had recorded a person was diabetic, we found information was recorded about additional checks carried out to maintain their health. For instance, eye screening and foot care.

Risk assessments were reviewed regularly or when changes in people’s needs occurred, for instance following a fall. In addition, we noted clinical observations were made after a person had fallen, in accordance with a written fall observation log. This process ensured their health did not deteriorate further and any concerns observed were escalated.

All staff had recently attended training on positive behaviour support to enable them to respond appropriately to behaviour that communicates a need, emotion or distress.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. We found some areas of improvement.

We found 2 store cupboards containing hazardous items were unlocked on two occasions during our visit. This had the potential to cause harm to people if items were ingested.

We found food items were out of date for safe consumption and some food items had not been labelled to ensure they were used prior to an expiry date. We highlighted this to the provider who took immediate action. Improvements were required to ensure this did not happen again.

People benefited from a well-maintained environment, free from malodours, with good lighting and accessible signage enabling people to move around the home safely.

Maintenance staff undertook regular health and safety checks. We saw evidence all necessary routine maintenance and safety checks had been completed. The provider held up‑to‑date certificates for key safety systems, including gas safety, fixed electrical wiring, fire safety systems such as emergency lighting, alarms and extinguisher servicing, portable appliance testing (PAT), Legionella testing and lifting operations and lifting equipment regulations (LOLER) inspections for hoists and beds.

Ongoing fire drills and evacuations were undertaken and fire training was completed by all staff. Personal emergency evacuation plans were in place. Management and staff were able to tell us who would need support to evacuate from the home and the strategy to do so. The use of coloured stickers on bedroom doors meant that the fire service knew who needed support to evacuate in an emergency.

The provider made sure equipment, facilities and technology supported the delivery of safe care. We observed a lift was not working and it was attended to by maintenance staff within 10 minutes.

The provider did not always make 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.

People were supported by staff who had been recruited with robust recruitment processes.

Staff recruitment files contained full and robust checks as required, including a Disclosure and Barring Service check (DBS). A DBS checks for criminal convictions and inclusion on lists of people who would be unsuitable to work with people at risk. A review of nursing staff records confirmed each qualified nurse was currently registered with the Nursing and Midwifery Council (NMC). Registration numbers and renewal dates were verified using the NMC online register. All staff held appropriate and up‑to‑date registration with no lapses identified.

Staff had recently completed bespoke dementia training focusing on communication and positive behaviour support. Staff told us they had benefited from the experience. One member of staff told us, “I found it very useful”.

People were cared for by staff who were supported in their roles and given opportunities to develop their skills. They received regular supervision (one to one meetings with their line managers) to discuss how they were working.

There was a comprehensive training programme to develop and update skills, to meet people’s needs. Systems were in place to monitor staff compliance with training.

We received mixed feedback from people and their relatives about staff numbers. Comments included, “I don’t think there are enough staff, sometimes you can’t find anybody [staff]”, “During the week I think there are always plenty of staff about, although it always seems there are less people around at the weekends”, “There are always three carers on this floor, they are not always experienced some of the younger ones are not so experienced” and “Staff numbers are ok but you can’t always find someone [staff], I find it difficult to arrange formal meetings”. Another person told us, “There are clearly more staff on duty on the first and second floors but you don’t always see the same faces, there appears to be a system too where carers stay on this floor for two weeks, then go to the other floor”. We discussed this feedback with the provider and checked staff rotas. We found they did not indicate less staff at weekends. However, following our site visit the provider confirmed they had increased staffing levels.

We observed during one lunchtime period, there were periods of time when no staff were present in one dining room when people were having their lunch. However, in another dining room, 6 staff were present.

The registered manager advised us, they did need to use agency staff to cover gaps and absences of permanent staff. Information had been obtained from external agencies who supplied temporary staff to the home to ensure they had the right skills, experience and attributes to work with people.

We observed differences in the level of access to information shared with new staff and agency staff. This could have placed both people and staff at risk. For instance, on the second day of our inspection we observed a member of staff who was on induction shadowing duty was left alone in a lounge with people and a young student on placement who required supervision. We have asked the provider to consider the deployment of staff to ensure people’s needs were met.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People lived in an environment which was clean, and odour free and staff knew how to manage the risk and spread of infection. People and their relatives raised no concerns about the cleanliness of the home. One relative praised the staff for how they looked after their family member’s room, keeping it clean and tidy.

Cleaning schedules were followed, which included deep cleans on a regular basis.

People and their relatives were complimentary about the laundry facilities. Comments included, “When I see [relative] they are always clean and nicely dressed, the laundry here is good and our clothes are always washed”.

Staff had access to personal protective equipment (PPE), we noted gloves and aprons were stored on landings, at ends of corridors and behind a locked door. This did have the potential to cause a delay in staff accessing PPE in an emergency. We have asked the provider to consider if alternative storage would aid easier access to PPE for staff.

Staff had access to policies and procedures to ensure they kept up to date with any changes in guidance. Routine audits were carried out to assess the effectiveness of infection control and prevention systems.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We found improvements were required to ensure medicines which were subject to additional storage and checks. We provided feedback to the registered manager and provider who took immediate action to ensure stock was safely controlled. In addition, issues with medicines previously identified by the service, were discussed by the staff team and lessons were learnt to prevent a reoccurrence.

We observed staff administering medicines safely and discreetly. Staff were trained and assessed to be competent in medicine administration. Staff asked people if they needed any medicines prescribed for occasional use (PRN), such as pain relief. Additional guidance was available to staff on when, how and why to administer PRN medicines. Staff followed national guidance, and records were complete, clear and contemporaneous. 

Relatives described the support their family had with medicines as safe, well‑controlled and consistently delivered. One relative told us, “There is no fault with the medication regime.