Clare Mount

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 inspection we rated this key question inadequate. At this inspection the rating has remained inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to good governance of the service.

This service scored 32 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Shortfalls in the provision of safe and effective care had not been identified and actioned. Improvements within the service had been driven by the effective input of the local authority teams. However, it was evident that good, effective and safe provision of dementia care and person-centred care for whom the service was provided, was not understood and implemented by the registered manager and staff team. Although staff were kind and gentle, care delivery was generic and task led without any reference to good therapeutic strategies to provide meaningful interventions to people living with dementia and manage people’s distressed behaviours.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

We were not assured the registered manager was always present at the home and fully involved with the running of the home. Information was not always readily available when we requested it. We made one safeguarding referral to the local authority relating to allegations made by one person living at the home and their isolated status. Actions were taken by the social worker to make improvements to their quality of life as a result of the safeguarding referral. However, the concerns we raised had not been identified and acted upon prior to our inspection. We were not assured that all safeguarding concerns were reported, as is a requirement of registration, as we had not been notified of 2 previous concerns raised by the palliative care team. We found continued concerns with the storage of confidential information; care records containing confidential records, including medical information, were stored in the staff locker room and this door was open and accessible throughout the inspection visits.

People did not always feel they could speak up and that their voice would be heard.

The provider did not operate an open and accessible complaints system as people and their relatives were not enabled through the provision of accessible information on how to make a complaint and who to make the complaint to.

During, and subsequent to this inspection, we received anonymous whistleblowing concerns about the treatment of staff. However, staff did not raise any concerns with us during our site visits.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us they felt supported in their role. Staff completed equality and diversity training and they employed and supported a diverse workforce. However, we were not assured staff were always treated fairly as anonymous concerns shared with us relating to the treatment of staff suggested staff were not always treated with equity.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We found repeated concerns at this inspection and this demonstrated a failure to ensure improvements were embedded and sustained. We found continuing concerns relating to the environment, the management of people’s individual risks, the provision of person centred care, need for consent and the effective support for people with dementia. We also identified concerns with the management of medicines at this inspection. Although audits and reviews were taking place, they had not identified the concerns the inspection team found, and where concerns had already been identified, these had not always been addressed and actioned. Despite the local authority working with the home to implement an action plan, concerns raised at the last inspection and set out in the inspection report and the warning notices, had not always been addressed fully.

Clare Mount has now been rated requires improvement or inadequate for the last five inspections and we have identified multiple and repeat breaches of Regulations. This is evidence of a history of failing to respond adequately to serious concerns and shortfalls set out in inspection reports and enforcement actions.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The registered manager told us they had plans to involve people in the community; however, there was nothing in place at the time of the inspection in terms of community involvement in the home. Although the home was currently working closely with partners agencies within their improvement plan, there was limited evidence of partner working and effective communication regarding working together to meet people’s needs. Feedback from other health and social care professionals involved in the home was that positive improvements were being made since the last inspection.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Although feedback from local authority was positive, we found continuing concerns relating to the provision of care delivery and how people experience their day-to-day living at Clare Mount. We were not assured that people’s risks were competently assess and monitored, and that learning from previous incidents was effectively and safely managed. We did not see evidence of a robust system in place to ensure the effective review of safety concerns, incidents and safeguarding concerns. We were not assured that all incidents were reported and addressed appropriately. We were not assured that previous concerns identified and raised led to continuous improvement and learning shared across the home. This placed people at the risk of harm and we were not assured people were always safe and receiving good quality, effective care.