Clare Court 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. At our last assessment we rated this key question inadequate and found a breach of regulation. At this assessment, the rating has changed to requires improvement. This meant management and leadership was consistent and had enabled improvement. However, some systems had not identified safety concerns found during the assessment. This meant the service remained in breach of regulation. Leaders and the culture they created supported the delivery of higher-quality, more person-centred care. Systems in place to monitor incidents and accidents were improved and enabled lessons to be learned.

This service scored 62 (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 shared a culture of improvement and continued development. Plans were in place to continue to improve the service in collaboration with people using the service and the staff team.

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. The management team were very responsive to our findings during the assessment. When we found improvement was needed, or inconsistencies in information shared, they were receptive to these observations. They addressed concerns and were transparent about the steps they were taking to mitigate future risks. The management team were alert to the challenges faced by the staff teams of a succession of changes in leadership. They spoke with pride about the hard work and achievements of the team. Staff and people told us about the visibility of the management team. Some staff told us the managers would provide hands on support when needed at busy times, for example during lunch. Staff were clear in their understanding of their roles and responsibilities. One staff member told us, “The manager is nice and listens to the staff and does walk arounds.” A relative commented, “The new manager is making lots of improvements. We can see the difference.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff and the management team told us there was a culture of speaking up at the home. Staff told us if they had concerns, they would share them with the management team. Some relatives told us they had been unhappy about the time taken or the response to complaints historically. However most felt there had been an improvement in the responsiveness of the staff team and the care provided to their loved ones. Staff we spoke with understood how to whistle blow if they had concerns about the conduct of others. We saw evidence the management team were open when things had gone wrong and had apologised to those effected.

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. Active steps had been taken to ensure staff and leaders were representative of the population of people using the service.

We saw significant improvement in systems in place to monitor the safety and quality of care provided. However, we found instances where roles and responsibilities around fire safety were not clear. We found concerns which had not been detected by the services quality assurance systems. Fire safety policies and procedures and the fire evacuation policy had been reviewed. However, the fact that they gave different information about who should lead in a fire emergency had not been identified. Fire risk assessments and safety checks had been completed by the management team regularly. These checks had not identified that fire signage was not giving the same advice as the fire safety procedure about what action to take. Staff told us they had completed training and fire drills. However, they seemed unsure about whether people would need to be evacuated and what steps to take to keep people safe. The management team had ensured staff had completed fire drills. However, they had not identified a lack of detail in the fire drill records. This made it difficult for the management team to assess staff progress and performance when responding to fire emergencies. One staff member we spoke with was not familiar with personal emergency evacuation plans (PEEPS) or the fire zones within the home. Systems had not ensured the staff conducting the fire drills had sufficient training to do this safely and effectively. We also saw checks of guidance for covert medication administration had been conducted by the management team. These checks had not identified guidance for staff was not verified by an appropriate professional. We found no evidence relatives of people who could not consent to covert medicines had been involved in the decision to conceal the person’s medicines from them. Checks completed on the covert medicine’s guidance had not identified this. Although we saw evidence staff had been provided with guidance and training on the importance of recording people’s meal and fluid consumption accurately. We also found examples where records suggested people had eaten a full meal when they had eaten either nothing or very little. Systems had not ensured staff were following correct recording processes for people’s meal consumption. Inaccurate records could lead to difficulty in diagnosing or addressing issues people were having with eating and appetite. We also saw one person who was at risk from a particular product had not been fully protected from this risk. The person’s risk assessment and care plan guided staff to make sure these products were locked away. However no formal checks were in place to ensure this instruction was being followed. This could have led to avoidable harm for the person. All the concerns we identified were addressed during the assessment by the management team, to ensure people were safe. We did see significant improvements in systems to ensure incidents and accidents were investigated and acted upon appropriately. We reviewed systems to ensure people cared for in bed were regularly checked in on and received company and engagement in activities if they wanted them. These had been improved. Staff had clear guidance on how often people needed to be checked on. The electronic system in use prompted staff to ensure these checks were made in a timely way. Data and safeguarding concerns were being shared consistently with external organisations as required. This meant funding and safeguarding teams could review actions taken to enable learning and future mitigation of risk after an incident or accident. Systems to oversee infection prevention control measures had ensured the home was clean, tidy and had no malodour.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people wherever possible. They shared information and learning with partners and collaborated for improvement. The service worked alongside a variety of service providers to ensure people’s needs were met. These included dentistry, chiropody, SALT (speech and language team), occupational health, the tissue viability nursing team, the local GP surgery, the pharmacy, and the adult safeguarding team. Some professionals working in partnership with the service gave feedback commending them on the improvements in care provided. One partnership healthcare provider commented on the ‘very good working relationship’ they had with the deputy manager, seniors, and nursing team.

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 and effective practice. Newer senior managers were supported by senior managers who knew the service well to support and enable them to consolidate learning and development and ensure important information was not lost. Processes in place enabled lessons to be learned when things had gone wrong. For example, a person had been identified as at risk from falling out of bed but could not safely have a bed rail as they may try to climb over it. Their bed was positioned on the lowest setting and padding was placed next to the bed so the person could roll onto this but was not able to fall.