The Care Quality Commission
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  • Care home

Clarence House Care Home

Overall: Requires improvement read more about inspection ratings

West Road, Mexborough, South Yorkshire, S64 9NL (01709) 578889

Provided and run by:
Crown Care VI Limited

All Inspections

During an assessment under our new approach

Date of assessment: 14 August to 2 September 2025. Clarence House Care Home is a nursing home which provides personal care and nursing care to adults, some of whom were living with dementia or physical disabilities. Up to 78 people can reside at the service. At the time of the inspection 65 people were living at the service. We inspected the service due to concerns shared with CQC about the quality of care being delivered. We carried out a comprehensive assessment of the service covering all 5 key questions and all quality statements. We found breaches of legal regulations in relation to good governance and safe and effective staffing.Feedback from people, their relatives and staff indicated that staffing was an issue at the service. There was a lack of oversight of care taking place and staff did not consistently receive supervision in line with the provider’s supervision policy.There were issues with the safety of the environment and infection prevention and control measures within the home, which staff and leaders within the service had not recognised. This included cleaning products not being locked away, furniture stored in stairways and rusty equipment. Care and support were not always delivered to a consistently high standard. Observations of care showed that some staff offered, kind and compassionate care to people, delivered patiently. However, some observations showed some staff not engaging with people or engaging in a task focussed manner. There was very little social stimulation or activity taking place in the service. Some people were observed to have very minimal interaction with people throughout the day. An activities coordinator was in place, however this was insufficient to meet the well-being and social needs of the service. The provider had recognised this and was in the process of recruiting more staff to the activities role. People’s care plans did not always contain information that was accurate or up to date despite records having been reviewed by staff. Recorded observations of care, for example food and fluid charts, were not always completed in line with professional advice. Governance and auditing within the home, although taking place, had failed to identify and address the concerns we found at our site visit. Following the site visit the provider has undertaken a number of immediate actions to address the concerns and has taken steps to gather feedback from people and strengthen leadership and oversight within the service. These improvements will take time to implement and embed.
 

During an assessment under our new approach

We carried out an assessment of Clarence House which commenced on 11 November 2024 and ended on 21 November 2024. Clarence House is a ‘care home’ that provides care and support to older people. Some people were living with dementia. The service can accommodate up to 78 people. At the time of the assessment 56 people were living at Clarence House. We carried out this assessment to check improvements from the previous inspection and to assess if the provider had addressed the concerns we previously raised. These concerns were in relation to infection prevention and control, governance and ensuring risks associated with people’s care, were identified and managed to keep people safe. At this assessment, we looked at Safe, Caring and Well Led Key Questions. We found the provider taken action to address the concerns and made changes which had improved the service.

14 November 2023

During an inspection looking at part of the service

About the service

Clarence House is a residential care home providing nursing and personal care for up to 78 people. At the time of our inspection there were 52 people using the service.

People’s experience of the service and what we found:

Quality monitoring systems were in place; however, these were not always effective. Some areas of improvement we identified during the inspection were not highlighted as part of the providers quality monitoring systems. For example, we found infection control shortfalls throughout the home including the kitchenette area and people’s ensuite facilities. Risks in relation to people’s care were not always being managed safely. Following our inspection, the registered manager took action to address these concerns. However, new systems and approaches required embedding into practice.

People did not always receive person centred care which took in to account their preferences. We received mixed views from people and relatives about the care and support.

People predominantly received their medicines as prescribed. However, we found some discrepancies mainly around record keeping relating to medicines management.

Staff told us they received training in safeguarding and knew what action to take if they suspected abuse.

The provider had a process in place to safely recruit staff. We observed there were enough staff available to support people.

Accidents and incidents were recorded, and action was taken to reduce future risks. The registered manager kept a record of safeguarding concerns and could evidence actions they had taken to protect people.

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.

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 16 August 2017).

Why we inspected

We undertook a focused inspection to review the key questions of safe, caring and well-led only. For those key question not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Clarence House on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to infection control, risks associated with people’s care and good governance.

Please see the action we have told the provider to take at the end of this report.

Follow Up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

18 March 2021

During an inspection looking at part of the service

Clarence House provides accommodation and support for up to 78 older people, with a range of support and care needs including people living with dementia. There were 38 people living at the service at the time of the inspection. The home is divided into four units, although the registered provider was using three of the units at the time of the inspection.

Effective systems were in place to ensure visitors to the service followed government guidelines for wearing Personal Protective Equipment (PPE). Facilities were available for visitors to sanitise their hands and put on PPE. Screening questions and a temperature check were standard requirements for all visitors. Staff supervised all essential visitors to ensure social distancing and infection control guidelines were followed.

People were supported to maintain contact with their relatives in different ways including telephone and video calls, and window visits. The service had created a visiting pod to reduce the risk of spreading infection. The entrance to this was separate to the main entrance of the home. The service had implemented a system to allow contact visits following recent government guidelines.

All staff were trained in safe infection, prevention and control (IPC) practices. We observed staff wearing appropriate PPE and sufficient supplies were available. The service had implemented a uniform policy to reduce the risk of spreading infection.

A programme of testing for COVID-19 was in place for people who lived in the home and staff. There had been a good uptake of people and staff receiving the COVID-19 vaccine.

The environment was clean, hygienic and well ventilated. Cleaning schedules were in place and being followed. The service's IPC policy was up to date and in line with current guidance. The service had plans in place and knew how to respond to an outbreak of infection to ensure the safety of people and staff.

20 June 2017

During a routine inspection

The inspection took place on 20 June 2017 and was unannounced. This was the first inspection of the home under the current registration.

Highgrove Care Home is a 78 bed nursing home, providing care to older adults with a range of support and care needs. At the time of the inspection there were 26 people living at the home. The home is divided into four discrete units, although the registered provider had stopped using two of the units and therefore, only two units were in use at the time of the inspection.

Highgrove Care Home is located in Mexborough, a small town in Doncaster, South Yorkshire. The home is known locally as Highgrove Manor. It is in its own grounds in a quiet, residential area, but close to public transport links.

The service had a registered manager who had been registered with the Care Quality Commission since February 2016. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us they felt safe living at the home. Assessments identified potential risks to people, and management plans were in place to reduce these risks. Recruitment processes were safe and we saw there were sufficient staff on duty to meet people’s needs.

Systems were in place to make sure people received their medications safely, which included key staff receiving medication training and regular audits of the system. Although, at the time of the inspection one room where medicines were stored was too warm.

It was a very warm day and periodically, we noticed a smell of urine in one particular area of the home. However, all other parts of the home looked clean and did not smell.

People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Staff had completed an induction and essential training at the beginning of their employment. This was followed by additional training and periodic refresher sessions. They also received regular support and supervision to help them meet people’s needs.

People were supported to eat and drink to maintain a balanced diet, and snacks were available between mealtimes. The people we spoke with said they were happy with the meals provided.

The registered provider had appropriate arrangements in place to ensure they adhered to the requirements of the Mental Capacity Act 2005.

People were treated with respect and kindness. Staff demonstrated a good knowledge of how to respect people’s preferences and ensure their privacy and dignity was maintained.

Relatives had been encouraged to be involved in planning their or their family members’ care. Care plans checked reflected people’s needs and had been reviewed and updated to reflect people’s changing needs.

People had access to social activities, as well as outings into the community.

There was a system in place to tell people how to raise concerns and how these would be managed. People told us they had no complaints, but would feel comfortable raising any concerns with the registered manager.

There were systems in place to assess if the home was operating correctly and people were satisfied with the service provided. This included meetings and regular audits. Action plans were in place to address any areas that needed improving.