Clarendon House Care 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.

This is the first assessment for this service since registration. This key question has been rated Good.This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 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 were aware of the core values of the organisation and told us senior, staff including the registered manager, demonstrated these on a daily basis.

A relative told us the service had a “strong manager that gets things done; they are fair to staff and will look to promote where possible”.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

People, their relatives and staff all stated the home had “settled” and “improved” since the current registered manager had been in post. One relative told us, “Now things are run much better, the staff clearly know their jobs a lot better, the atmosphere is a lot happier, and the staff are clearly happier too”.

People told us they had confidence in the registered manager. One person said “they [the registered manager and deputy] work well together. We have seen massive improvement since [the registered manager] came”.

A staff member told us, “Things have really settled down since [registered manager] came, things have improved and most importantly, she comes to me and asks my advice, and I am happy to tell her”.

People and staff told us the registered manager was approachable. Comments included, “Yes, I know the registered manager and we know that we can see her if we need to”.

Staff also provided positive feedback about the nominated individual. The nominated individual are responsible for overseeing the quality and safety of the service and ensuring compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations. Staff told us they were approachable and supportive.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People and their relatives told us they felt able to express their views confidently, and most told us they were comfortable raising both positive feedback and concerns. People spoke openly about changes they had noticed, including routines around personal care, staffing levels, and the way activities were organised. Relatives regularly shared observations about their family members’ wellbeing and described staff as approachable and willing to listen. Several relatives told us they were “fully involved” in care planning and felt consulted about decisions such as equipment changes, which showed their voices were valued by staff.

People stated that the culture had become more open under the current registered manager. Relatives reported the atmosphere was more positive and staff appeared happier and more confident. They said they could approach the registered manager easily and communication had improved. Some noted they had received recent surveys and had opportunities to participate in one‑to‑one discussions with senior staff, which supported them to express themselves in a safe way.

The registered manager was able to provide examples of how people’s voices have been heard and acted upon. One example was when a person had spoken with the managing director about their daily life and occupation within the home. The person’s views had been listened to, and they had given further opportunities to drive improvement on types of activities offered to other people.

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 their wellbeing had been supported. Comments included “it is promoted, I feel very supported” and “very much so yes”.

People were supported by a diverse group of staff which represented the local community. The provider was able to support staff whilst they observed religious holidays and practises. For instance, at the time of our assessment Ramadan was being observed by a number of staff.

The provider’s policies and procedures supported an inclusive culture where all people and staff were respected, and their differences celebrated. The registered manager told us they had introduced an international food day. They said, “This approach not only values residents’ voice but also promotes cultural awareness and respect within the home.”

People had the opportunity to vote for an employee of the month; staff told us this had promoted their wellbeing and they liked to get positive feedback.

The provider had clear roles and responsibilities, and staff understood who was accountable for key areas of the service. However, the systems in place to monitor quality and safety were not always effective in driving timely improvements. We found national best practice guidance was not routinely taken into consideration, which had the potential to limit positive outcomes for people.

People living with dementia did not routinely benefit from an environment which aided their orientation or minimise potential distress from visual perceptions of their environment.

We found routine audits had been undertaken and highlighted some areas of improvement; however, we also found the same concerns were still present when we visited. For instance, monitoring of out-of-date food and hygiene in kitchenette areas. We found daily notes did not routinely reflect the support people had received at the time they had received it.

We found routine monitoring documents were not always completed correctly, we found incident forms did not always have the correct time for when the incident occurred, these had the potential to limit effective monitoring of people’s health. We discussed this with the registered manager, who addressed the importance of accurate recording with the relevant staff to ensure improvements were made. We have asked the registered manager to ensure accident and incident records are completed correctly.

Some language used across care plans and daily notes was not always in accordance with a person-centred approach. The registered manager understood the importance of ensuring language remains focused on people’s experience and promotes dignity at all times. The registered manager confirmed these expectations have been shared with all staff.

We found some documents that were incomplete including a Personal Emergency Evacuation Plan (PEEP). The evacuation register was not up to date with a change in occupancy.

We found other records used to help monitor the service were not always accurate. For instance, a supervision matrix used to monitor when one to one meetings were held with staff and their line manager did not routinely reflect when meetings had been held. We discussed this with the registered manager who indicated there were omissions on the staff supervision matrix and staff training spreadsheet, they were able to provide us with the accurate information.

We provided feedback to the registered manager and provider on improvements required regarding the accuracy of records.

The provider clearly understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.

We were provided with many examples of how Clarendon House had integrated into the local community and so quickly for a relatively newcomer to the local area.

People had opportunities to have social events with family and friends, both within the care home and at local community venues. These included summer barbeques, summer fetes held at the local primary school, singing sessions with preschool aged children and picnics in the local green spaces. In addition, people were supported to visit local National Trust properties.

People invited the local community to a weekly coffee morning; this provided them with a sense of community and self-worth. The care home was used as a base for monthly poetry sessions, provided by a local poetry group, People, their relatives and friends were all welcomed to attend.

The service had links with colleges and supported work placements for health and social care students.

The home had forged links with the local university based in the same town. In particular, an academic specialising in chronic pain. The registered manager informed us they were looking forward to further developing a working partnership with the university in the future.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The registered manager had implemented a number of activities to ensure staff were learning from events and developing their skills to ensure people received good care. The registered manager told us, “Our daily flash meetings and monthly clinical governance meetings ensure effective communication, swift action, and shared learning. Flash meetings allow immediate follow-up of incidents or health changes, leading to timely referrals to dieticians, physiotherapists, and GPs.”

Staff had completed a virtual dementia experience. The registered manager told us it had provided, “An immersive experience, offering insight into living with dementia. This has transformed empathy, communication, and understanding across the team, significantly improving the quality of dementia care.” We provided some feedback to the registered manager about how this could be further developed with staff, to ensure good communication with people living with dementia.