Clement Court

Date of assessment: 5 February to 10 March 2026, with site visits on 5 and 17 February 2026.

The inspection was undertaken to follow up on concerns identified at the last inspection to make sure improvements had been made as we had continued to receive concerns about the service.

At the last inspection the provider was in breach of regulations about safeguarding people and the governance of the service.

At this inspection enough improvements had been made so the provider was no longer in breach about safeguarding concerns. However, the provider continued to be in breach of regulations about the governance of the service. At this inspection the provider was also in breach of more regulations. There were concerns about the management of medicines and the cleanliness of some people’s equipment and people were not always being supported in a person-centred way.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

At this inspection, we found the provider’s systems for learning from incidents were not always effective. People were not always protected from effective safeguarding systems, although we did see when incidents had been recorded, they were reported promptly. However, people’s rights were not always being protected as some people were being restricted in bed. People’s care plans did not always detail the reasons people remained in bed. However, in other areas people’s plan contained personalised detail.

The environment was not always free from avoidable risk, such as hot water being too hot, radiator covers not being secured, window restrictors were in place but not always tamper-proof and a service lift was unsecured.

The provider did not always make sure there were enough qualified, skilled and experienced staff deployed to meet people’s needs. Staff were recruited safely to ensure they were suitable work with people who used the service. The provider did not always assess or manage the risk of infection. Medicines were not always managed or stored safely.

The provider worked with other health professionals to try to keep people well. While staff worked with other professionals the home was described as ‘chaotic’ at times and difficult to get hold of staff. Despite this, referrals to professionals were timely and appropriate. People had their health needs monitored to help them stay well. Staff were able to tell us about how they supported people right to make choices, but assessments of people’s ability to make decisions were not always detailed and there was not always evidence a decision was in a person’s best interest.

Staff were task oriented in order to tick off tasks that had been completed on the provider’s electronic system where people’s care was documented. Staff gave mixed feedback about feeling supported, but they felt the new management team were making a difference.

The provider did not always make sure people were at the centre of their care. The provider did not always ensure people were at the centre of their care. Staff generally knew people well; however, they were not always able to explain the reasons why some people remained in bed.

Care plans contained personalised details, but the records of ‘This is me’ did not evidence how people were being supported to achieve their goals. Care plans were available in other formats for people. However, the provider had identified improvements were needed to how people were supported to make meal choices and this improvement had not been embedded. There was a complaint policy and process in place to ensure people and relatives could raise concerns.

People did not always have equity in experience and outcomes as they were not always supported to use communal areas or get out of bed at a reasonable time. Generic end of life care plans were in place and individual emergency treatment wishes were in place for those who wanted this.

There was not a person-centred culture within the service. There was a new management team in the service, which staff were positive about. However, they had not been in post long enough to affect enough change and embed the required improvements. There was mixed feedback about how able staff felt speaking up if they had concerns, but the provider did have a policy in place about this.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. The provider understood their duty to collaborate and work in partnership. However, the provider did not always share information and learning with partners or collaborate for improvement. The provider was receptive to feedback and willing to learn from mistakes, but they had failed to fully address ongoing concerns which meant people experienced poor care for an extended period.

Date of Assessment: 23 and 24 April 2025. Clement Court is a residential home providing personal care and nursing care to older people, some of whom are living with dementia.

At the time of the inspection the service supported 71 people. This inspection was prompted by concerns raised with us about the safety and management of the home. At this inspection we looked at the safe and well led quality statements only. At our last inspection the service was in breach of legal regulation regarding the safety of the physical environment and governance. We have noted improvements with the physical environment had been made and the provider is no longer in breach of this regulation. However, they continue to remain in breach regarding the governance of the service. Additionally, we have identified concerns in relation to safeguarding people from abuse and improper treatment. The provider failed to ensure people did not receive unnecessary restrictions to their day-to-day experiences. They failed to ensure staff supported people in a way which was safe and in accordance with their individual risk assessments.

The provider did not complete effective quality checks to drive good care.

People could not be assured they would consistently receive their prescribed medication as directed. People could not be assured staff followed effective infection prevention and control practices at all times, or the furniture they used was safe and fit for purpose.

Staff felt despondent, unsupervised and that there was a lack of direction from the management team. The provider failed to investigate all incidents reported to them or to make timely notifications to the local authority to ensure openness and transparency.

The provider followed safe recruitment practices. People were referred to other healthcare partners when it was appropriate.

People had developed good relationships with core staff members but did not understand what was happening with the management within the home or how this potentially impacted on the care and support they received. The provider encouraged effective working relationships with other health care partners including district nurses, pharmacy and GP services.