Clarence 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. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to staffing.
 

This service scored 50 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. Some work was undertaken to document and address incidents, for example the service did undertake falls analysis and made individual referrals for people who fell frequently, and the number of falls occurring was documented. However, some staff told us they felt raising concerns would impact on how they were treated at work. However, some staff told us they did not feel confident raising concerns and that the service did not have a supportive or coaching environment where they felt able to speak candidly about their concerns so that these could be addressed.Records were in place to support staff to reflect on incidents. However, these were only partially completed and there was no evidence that these were used in any meaningful way to create change within the service.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care. Feedback from professionals regarding working with the service was mainly positive. Professionals told us staff tried to implement changes to the best of their ability, however staff were busy. Professional feedback differed in relation to how quickly they were alerted to changes in people’s needs. One professional told us, “Sometimes they can be slow on deterioration and referral”, while another professional said, “[Staff] ask for reassessment when people deteriorate, they are good with this.” Records showed that professional advice was not always updated in people’s care plans and was not always followed consistently by staff. For example, 1 person's care plan had not been updated with recommendations from a dietician, and records did not evidence that recommendations for weekly weigh ins and offering fortified snacks were implemented consistently.

The provider worked with people and healthcare partners to share information about safeguarding with events when required. Staff understood what was meant by safeguarding and had undertaken training in this area. When issues were identified, the relevant agencies were informed.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Feedback from relatives was mixed about the level of care provided to their relatives and how much involvement they were able to have in relation to care planning. A relative told us, “The manager takes on board my suggestions, staff inform me of everything” while another relative said, “I have asked to see the care plan, but they don’t involve us in it.”
Some staff providing one to one support with people did not have access to people’s care plans or records and told us they received information about people’s needs from staff on duty at the start of their shifts. Staff providing one to one support could not consistently recall important information about the people they were supporting. One member of staff was able demonstrate a clear and detailed understanding of the needs, preferences and de-escalation techniques required for the person they were supporting. However, another member of staff could only supply limited information about why they were supporting the person and what they would do in the event the person became upset.
 

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. The provider had records of checks that were undertaken to assess the safety of the environment. However, these processes had not ensured that risks were identified and addressed. Items which could pose a risk to people were not consistently stored safely. Some cupboards and storerooms containing chemical cleaners covered by the Control of Substances Hazardous to Health Regulations (COSHH) were unlocked and in 1 dining area a drinking glass filled with washing up liquid was left unattended on a worktop. This was in an area where people living with dementia were cared for and created a potential risk for accidental ingestion. Managers took immediate action to rectify these issues. Stairways on the bottom and middle floors of the building were being used as storage areas, this included mattresses and planks of wood stored on stairs. These items would impede evacuation in the event of an emergency such as a fire. During a second site visit the provider evidenced that they had taken immediate actions to rectify the issues found on the first site visit.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs. People, their relatives and staff told us there were insufficient staff at the service. People told us, “They are rushed off their feet, there aren’t enough staff” and “I asked a staff member to take me to the toilet and they said, ‘Oh it’s ok, you have your pad on.’” Relatives raised concerns about staffing levels and the conduct of some staff. Relatives told us, “The lounge area is meant to have a member of staff in there, but 90% of the time it doesn’t, the other day a member of staff was asleep in there” and “There is definitely not enough staff, you can sit in the lounge for 30-40 minutes and no one comes in.”
There was insufficient oversight of care delivery within the home to ensure people received support in line with their agreed plans. Inspectors observed that some people had personal information about their care needs on display on their bedroom doors. When this was queried, the registered manager advised that this was due to relatives sometimes completing care tasks within the home with people who were not their relatives. A relative told us, “There’s not enough staff around, I know I’m not supposed to, but I try to help residents if there’s no staff around.” This placed people at risk of avoidable harm.
The service was not operating in line with its supervision policy which stated staff should receive a session of supervision every 2 months. Records showed that not all staff received supervision within these timescales. Feedback from staff regarding supervision was mixed, some staff advised that this was received and was useful, however some staff said they had never received supervision despite having worked at the home for considerably longer than 2 months.
Recruitment was completed safely and in line with current guidelines.
 

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. Inspectors observed that some furnishings and equipment were not sufficiently maintained. One lounge chair had a ripped cover and rust was found on equipment used by people to support with showering. This created and infection prevention and control (IPC) risk as items could not be cleaned effectively with damaged surface areas. One shower room was found with stains on the floor and wall, a missing drain cover and a strong malodour in the room. A chair cushion insert was found to be stained and malodourous. Although a cleaning regime was in place in the home and IPC audits were taking place, these had not been effective in identifying and addressing the issues found. The provider took immediate action to address the concerns.

The provider made sure that medicines and treatments met people’s needs. There were some areas for improvement, however medicines were mainly managed safely. The service had systems in place to safely store, administer and record the use of medicines. However, these were not always followed, in that instructions for medicines which should be given at specific times were not always available. Administering medicines as directed by the prescriber reduces the risk of the service user experiencing adverse effects from the medicine. Temperature records to ensure the safe storage of medicines were not completed in accordance with national guidance. This meant we could not be assured that medicines requiring refrigeration were safe for use.
The service had individual fire risk assessments in place for people who were prescribed paraffin-based skin products. Detailed guidance specific to each person on how to administer medicines prescribed as and when people required them, known as “PRN” was available to staff.
We checked the quantities and stock balances for fifteen people and found them to be correct. This meant we could be assured that the correct doses of medicines had been administered as signed for by staff. Two people were prescribed a medicine administered via a patch which needs rotating to different areas of the body, as recommended by the manufacturer. We found there was a process in place to indicate the site of the patch application. This prevents the patch being placed on the same site too frequently. The use of topical creams and ointments were recorded on the medicines administration records (MARs). Body maps were in place to show staff the site of application. One person was being given their medicines covertly (disguised in food or drink). Appropriate assessments had been undertaken, and documentation was in place. Thickeners used to thicken fluids for people with swallowing difficulties were recorded when they had been used. One person was unable to take their medicines by mouth. Guidance was in place to enable trained staff to safely administer appropriately prescribed medicines into a stomach tube (Percutaneous endoscopic gastronomy), also known as PEG. Handwritten MARs were signed by two members of staff to confirm dosage instructions had been transcribed accurately. MARs contained photographs of service users to reduce the risk of medicines being given to the wrong person. All records clearly stated if the person had any allergies, reducing the chance of someone receiving a medicine they are allergic to. People’s preferences of how they wanted their medicines to be administered were recorded. There were appropriate arrangements in place for the management of controlled drugs (medicines that require extra checks and special storage arrangements because of the potential for abuse). Records showed that staff completed regular balance checks in accordance with national guidance. There was evidence that there was a process in place to record medicines related incidents or errors. Staff told us they had completed a training and induction process for medicines management. Staff competencies were assessed regularly to make sure they had the necessary skills. Managers and members of staff qualified to handle medicines regularly completed audits (checks) to make sure that procedures were followed. However, the shortfalls we found during the site visit had not been identified.