21 August 2021
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
The inspection was carried out by two inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Clarendon Mews Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
At the time of this inspection the service did not have a manager registered with the Care Quality Commission. Two managers had applied to share the registered manager position and the applications were in progress. This means that once registered they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We also sought feedback from Healthwatch Leicester. Healthwatch are an independent consumer champion that gather and represent the views of the public about health and social care services in England.
We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.
During the inspection
We spoke with eight people who used the service and four relatives about their experience of the care provided. We spoke with six members of staff including care staff, catering staff, managers and the provider / nominated individual (NI). The NI is responsible for supervising the management of the service on behalf of the provider.
We reviewed a range of records. This included eight people’s care records and multiple medication records. We looked at four staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records.
21 August 2021
About the service
Clarendon Mews Care Home is a residential care home that provides personal and nursing care for up to 47 people. At the time of the inspection the service was supporting 41 people.
People’s experience of using this service and what we found
The provider had improved the systems to oversee and monitor all aspects of the service. However, some monitoring records had gaps where staff had not recorded when they had carried out night checks as specified in people's care plans. We also found gaps where staff had not consistently recorded when they had assisted people at risk of developing skin pressure damage to move position, as specified in the care plans. The provider confirmed the care monitoring systems would be further strengthened so that any gaps in monitoring people’s care and support could be quickly identified and acted upon.
The systems to safeguard people from abuse or improper treatment had been improved. All staff had received refresher safeguarding training. The provider informed the local safeguarding authority and the Care Quality Commission (CQC) of safeguarding concerns. Records showed investigations followed the local authority and providers safeguarding policies.
Incidents of safeguarding and serious injuries had significantly reduced. The systems to investigate and follow up incidents, accidents and falls had been improved to identify and mitigate the risks of repeat incidents. This demonstrated a commitment to lessons learnt, to continuously improve the safety and care of people living at the service.
An electronic personal care monitoring system had been introduced and most people’s care records had been transferred onto the system. We found the care plans that had been transferred onto the system were very detailed.
Risks associated to people's eating and drinking were clearly recorded and up to date. Practical measures had been put in place to reduce choking risks. All staff involved with supporting people to eat and drink had received specialist training on Dysphagia (choking risks). We observed staff sensitively supporting people that required additional support to eat and drink, whilst enabling people to maintain as much independence as possible.
Staff were trained in the safe administration of medicines and their competency was assessed before they administered medicines to people. Medicines were stored securely and administered to people as prescribed.
People's needs were assessed and people and / or their representatives were involved in the care planning and review process. Throughout the inspection we saw positive interactions between staff and the people using in the service. We observed people move freely around the environment. One person said, “They [staff] put their arms round me when I am mardy (upset). It shows that someone cares.” Relatives were very complimentary of the caring attitude of the staff team.
Staff were safely recruited recruitment files evidenced the provider applied for Disclosure and Barring Service (DBS) checks, to include a criminal conviction check and appropriate pre employment checks had been completed.
Why we inspected
This was a planned focused inspection based on the previous rating.
The last rating for this service was Inadequate (published 6 January 2021) and there were multiple breaches of regulation. We imposed conditions upon the provider's registration certificate.
The provider completed an action plan after the last inspection to show what they would do and by when to improve and meet the breaches in regulations: Regulation 10 Dignity and respect; Regulation 12 Safe care and treatment; Regulation 13 Safeguarding service users from abuse and improper treatment; Regulation 17 Good Governance and Regulation 18 Staffing.
We undertook this inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Caring and Well-Led which contain those requirements.
At this inspection we found enough improvements had been made and the provider was no longer in breach of regulations.
This service has been in Special Measures since 6 January 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.
The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Inadequate to Good. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Clarendon Mews Care Home on our website at www.cqc.org.uk
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.