Clare Court 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 inadequate. 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. At our last assessment we found concerns about failures in how people had been protected from possible abuse and neglect. This was a breach of regulation. At this assessment we saw improvements in how people were protected from abuse and harm; this meant the service was no longer in breach in this area. At our last assessment we also found a breach in relation to the quality of systems designed to ensure people’s care was safe and risks were managed and reduced. At this assessment, although we saw significant improvement, the service remained in breach of legal regulation in relation to fire safety management and making sure known risks were reduced wherever possible.

This service scored 59 (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. Safety systems enabled the management team to analyse the circumstances around falls and identify themes and trends. This enabled better management and reduction of falls risks for people. Lessons about when things had gone wrong were shared with the staff team during staff meetings. The management team had identified a number of ways in which the service could further be improved. For example, they told us about plans to switch to a better electronic care planning system. People benefited from improvements to their care as a result of an open learning culture within the team.

The provider collaborated 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. Systems were in place to ensure for example, if people went to hospital, up to date information was shared with the hospital team. This meant people were supported by staff who could learn quickly about key risks and health needs in the event of a medical emergency. We saw people benefited from support from a range of different health care providers and specialists in line with their needs. For example, if risks were identified for people with their eating and drinking, they were referred to the speech and language therapy team (SALT).

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. Staff we spoke with could identify safeguarding concerns and described appropriate action they would take. All the people we spoke with told us they felt safe living at Clare Court Care Home. For example, one person described how they were supported by staff with the use of a hoist to move around. They told us, “It’s all very very safe.” Another said, “I do feel safe here.” Relatives we spoke with also told us they felt their loved ones were cared for safely. One relative told us, “[My loved one] is definitely safe there.” Staff received training at induction and refresher training to ensure they understood and remained up to date with safeguarding awareness.

We saw many examples of the staff team working with people to understand and manage risks. However, we found some instances where staff had not managed and communicated risk effectively. Staff had identified a person was at a risk from specific products in the home. Their risk assessment guided staff to ensure they did not leave products out in the person’s room. However, we saw staff had not locked away these products, leaving the person at risk of avoidable harm. We brought this to the management team’s attention. They ensured the items were locked away. The management team added a prompt to check for these items to a daily checklist. This would remind staff to ensure the products were not left out again. We also saw staff had recently identified 2 people were at increased risk of choking. The care plan guidance for staff had not been updated to show this. When we shared this with the management team, they ensured the guidance for staff was updated. The management team verbally updated senior staff about these risks and asked them to make sure teams were aware of the changes needed. We saw records for 1 person who had been losing weight were not accurate. Records indicated the person had eaten all of their meal when they had not eaten any of it. The management team investigated this and took steps to improve recording of how much people had eaten. Risks associated with communication difficulties and supporting people with emotional distress were addressed in people’s care plans. Staff generally knew people’s needs well but were also supported with guidance to ensure communication was effective and people could be supported when distressed or in discomfort.

The provider did not always detect and control potential risks in the care environment. Plans to respond safely and quickly in the event of a fire emergency were not always clear. Staff we spoke with were not clear about how to respond in the event of a fire. Signage instructing people and staff on how to proceed in the event of a fire did not correspond with the evacuation plan and procedure. Two of the personal emergency evacuation plans showed 2 people were in the same room, which was not correct. However, the summary guidance of who was residing in which room was correct. When we highlighted these issues to the management team. They ensured the issues were addressed promptly. The management team took steps to ensure staff were aware of how to respond safely in a fire emergency. They oversaw the updating of signage to accurately guide people and staff. Plans were in place to support the team to respond in the event of other types of emergencies. We saw the home was tidy and uncluttered. The management team made sure equipment used to deliver care and treatment was maintained well and stored safely.

Although some concerns remained about staffing levels, the provider had taken steps to monitor and improve responsiveness to people’s needs. At our last assessment we found the provider had taken insufficient steps to ensure people were supported by adequate numbers of staff. At this assessment, we received mixed views about staffing levels. Some staff, people and relatives still had concerns that staff were too busy at certain times of day. One person told us, “Sometimes there’s not enough staff to help me walk. I just sit here then.” Another person said, “Sometimes they cut corners, particularly at night when they are very busy.” Another person told us, “There’s enough staff most of the time. If one is on holiday, it gets a bit more awkward.” However, others told us they were not concerned about staffing levels. One person said, “[The staff] always answer my buzzer quickly day or night.” Some relatives expressed concerns. One said, “[Staff] say there’s not enough staff to give [my loved one] a shower. It doesn’t happen often though.” Another told us, “I do think they need more staff, so many need help at mealtimes with eating and they need staff to take them to the toilet afterwards.” Additionally, another relative said, “It does appear sometimes there isn’t enough staff as there’s no one in the lounge or kitchen.” Other relatives said they felt the staffing levels had improved and were sufficient. One relative said, “There appears to be more staff around, definitely enough in the day.” Another told us, “I do think there’s enough staff. There is always staff around.” Staff also had mixed views on whether there were sufficient staff levels. One staff member told us, “I think we need more care staff as we have to come away from activities to support care staff.” Another staff member told us, “It is ok for now as we don’t have many residents.” During our site visits, we saw on a number of occasions when no staff in lounges whilst they were in use. Staff were allocated to be present in the lounge but were at times required to leave to attend to other care duties. We did see staff were never far away when needed. The management team had previously consulted staff about staffing levels. Staff had said another carer was needed in a specific area and this was agreed. Staff told us the managers supported them with care when needed and we saw them helping out at lunch times. The management team were reviewing a tool to predict how many staff they needed based on people’s care needs regularly. The management team were also reviewing how quickly staff were attending to call bells. Analysis of this showed staff were attending in under 5 minutes. We saw no evidence anyone had been harmed as a result of staff not always being present in the lounge areas. However, we did share observations and feedback gathered regarding staffing with the management team. They told us they had bank staff and would also seek agency staff if needed to cover any staff absences. They also observed staffing levels during walk arounds of the home. The management team gave assurance they were monitoring staffing levels on an ongoing basis. The provider made sure staff were qualified, skilled and experienced. Overall, feedback about the knowledge and experience of the staff team was positive. Some relatives shared concerns that newer staff were less experienced. One relative said they thought staff had needed more training to understand their loved one’s condition, but support for that person had recently improved. Staff told us they received effective support, supervision, and development. They also told us they generally worked together well as a team. Recruitment systems were robust and included checks to ensure applicants were safe and appropriate for their roles.

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.

At our last assessment we found carpets were malodorous and some table surfaces had become too damaged to clean and needed replacing. At this assessment we saw much improvement. The provider had ensured malodorous carpets had been replaced. The home was clean and uncluttered. Décor and maintenance of the home was improved, this included people’s bedrooms. People told us they were happy with the cleanliness of the home. One person said, “[Staff] come into my room regularly to clean it. It’s always very clean.” A relative told us, “There used to be a smell. It has improved a lot. The cleaners are really very good, I’ve seen what they do.”

The provider did not always manage medicines and treatments safely. There was no evidence of guidance from professionals about how to administer covert medicines. A covert medicine is administered by staff without a person’s knowledge or consent, usually by disguising it in food or drink. There was also no evidence people’s views and wishes, and those of their loved one’s had been considered regarding covert medicines. When we brought this to the management team’s attention, they sought the advice of the GP and pharmacist to ensure guidance was safe for staff to follow. They also invited loved ones to contribute to decisions about the need for covert medicines, in line with their health, but also their wishes and preferences. We found that in 3 instances medication records did not correspond with medicines in stock for people. In one instance, staff had not added a medicine to a person’s electronic record. There was no impact upon the person as the medicine was ‘anticipatory’ and not required at the time of our visit. In the other 2 instances we shared our findings with the management team who conducted investigations into this. The management team took action to try to mitigate the risk of stock counts of medicines being incorrect. There was no evidence anyone had been harmed as a result of these errors. People were supported by staff to have medicated creams applied as needed. Staff made sure medicines were stored safely and ordered for people as they needed them. Staff received appropriate training and checks to make sure they remained aware of how to provide medicines safely. People were supported safely to have ‘as needed medicines’ such as pain killers or laxatives. People told us they were happy with the support they received to take their medicines.