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Clarence House Care Home Inadequate

The provider of this service changed - see old profile


Inspection carried out on 1 October 2020

During an inspection looking at part of the service

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 carried out on 5 March 2019

During a routine inspection

About the service:

• Clarence House Care Home is a residential care home that was providing personal care to 36 people aged 65 and over at the time of this inspection. Some of those residing at Clarence House Care Home were living with dementia. It is registered to provide care and support for up to 41 older people.

• This was the service’s first inspection under a new provider.

People’s experience of using this service:

• The provider’s quality monitoring auditing system was not robust enough to identify and rectify the concerns we found at this inspection and what they themselves had previously identified.

• Good practice guidance and the provider’s own policy and procedures had not been followed in relation to the management and administration of controlled medicines.

• Although people received a person-centred service, care plans that lacked detail and recent reviews put people at risk of receiving care and support that did not meet their needs, particularly as a high number of agency staff were being used within the service.

• We saw that people were involved in making day to day decisions about the care and support they received. However, people’s involvement in the planning of their care was not evident.

• The individual risks to people had been identified and managed but written assessments of the risks lacked detail and reviews. This put people at risk.

• We have made two recommendations to the provider about care plans.

• Accidents and incidents were recorded and actioned but full analysis was not completed to fully mitigate future risk.

• The risks associated with the environment and working practices had been managed.

• Staff recruitment was safe and there were enough staff to meet people’s needs.

• The provider had systems in place to help protect people from the risk of abuse and infections.

• People were happy with the care and support they received as were their family members.

• Staff demonstrated respect for people and interacted in a kind and meaningful way.

• People’s independence was encouraged and virtual assistive technology was being employed to further enhance this.

• People experienced positive, social and engaging mealtimes and their nutritional needs were met. They had access to healthcare professionals.

• Staff were supported, inducted and received ongoing training to further improve the service people received. People told us they had confidence in the staff’s abilities to support them.

• There was an open and transparent culture within the service and suggestions and opinions on the service was encouraged, investigated and listened to.

• Staff worked well together and shifts were well organised.

• The environment was safe and warm. Refurbishment was ongoing.

• People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Accessible information was available to those that lived at the service and others in order to make informed decisions.

• Activities were provided that people enjoyed.

• Improvements to the service continued however we did not yet see the full impact of these at this inspection. The service met the characteristics of good in three key questions however concerns about the management of controlled medicines and issues with care planning meant the service was in breach of the Regulations in two of the key questions.

• For more information on our inspection findings, please see the full report which is on the Care Quality Commission (CQC) website at

Rating at last inspection:

• This was the service’s first inspection under its new provider. The regulated activity of ‘accommodation for persons who require nursing or personal care’ was registered with the CQC on 12 June 2018.

Why we inspected:

• This was a planned comprehensive inspection based on the service’s new registration.

Follow up:

• We will continue to monito