You are here

Clarence House Care Home Inadequate

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating


Updated 27 November 2020

About the service

Clarence House Care Home is a residential care home that provides personal care. It is registered to provide care and support for up to 41 older people. At the time of the inspection 31 people, some of who lived with dementia, were receiving personal care. Accommodation was over three floors of a period building which had been adapted.

People's experience of using this service and what we found

The provider’s quality monitoring and auditing systems were not robust enough to identify and rectify the concerns we found at this inspection.

Areas for improvement identified during the last inspection were not all rectified. This meant the provider had not implemented the right changes to ensure improvements were made.

The registered manager was not always aware of areas of concern about peoples’ care needs. This had placed people’s health and safety at risk. This had been due to poor documentation and also guidance within care plans.

Staff did not always report, document and monitor people’s needs as required to ensure appropriate care and support were in place. This meant that people were at an increased risk as we could not be sure if appropriate actions such as repositioning had always taken place.

Charts used by staff to monitor people’s care and support were not always completed. These included repositioning charts for people with poor skin integrity and fluid charts for people at risk of dehydration. This placed people’s health at risk of harm because the provider could not be assured that the appropriate care was being delivered by staff as required. People may not have received care and support to keep them safe.

Medicines were not always being managed safely at the home. We could not be sure that people were always receiving their medicines as prescribed.

People told us staff provided good care. However, there were not always enough staff to ensure people’s needs were met in a timely manner. This had an impact on people’s dignity and did not meet their care and support needs. This included supporting people’s independence to be able to go to the toilet when they needed or to have a shower when they wanted.

People’s care plans we looked at, lacked detail and information to ensure people were kept safe. We found where risk assessments were required for people’s known risks, these had not always been completed. This meant that people were placed at unnecessary risk because there was no guidance for staff to support the risks.

People lacked regular good interaction from staff due to staffing levels. People were not always involved in decisions about their care.

For more details, please see the full report which is on the CQC website at

Rating at last inspection and update

The last rating for this service was requires improvement (published 4 April 2019) and there was a breach of regulation17 good governance. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough, improvement had not been sustained and the provider was still in breach of regulations.

Why we inspected

We undertook this focused inspection to check they had followed their action plan and to confirm that they had met the legal requirements. This report only covers our findings in relation to the key questions safe and well-led which contain those requirements.

The inspection was prompted in part due to concerns received about staffing levels, medicine errors and several safeguarding’s raised with the local authority in relation to poor care.

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 requires improvement to inadequate. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the 'a

Inspection areas



Updated 27 November 2020

The service was not safe.



Updated 27 November 2020



Updated 27 November 2020



Updated 27 November 2020



Updated 27 November 2020

The service was not well-led.