Clement Court

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question good. At this inspection the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safeguarding people from abuse and improper treatment.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People could not always be assured they would receive timely analysis on any safety events which involved them or outcomes which minimised the risk of it happening again. The provider did not always have a proactive and positive culture of safety based on openness and honesty. The provider did not always investigate and report safety events in a timely way. Lessons were not always learnt to continually identify and embed good practice. The provider failed to identify several incidents of concern or report these to the necessary health care partners to ensure they were investigated or reviewed to identify any potential learning. For example, incidents which occurred in August 2024 had not been reported until March or April 2025. There was a lack of provider oversight which failed to ensure all incidents were reported when required. The provider failed to complete analysis of incidents accidents of potentially dangerous occurrences. For example, there was no trend analysis for incidents to identify what had happened, when or why. This failure to complete such analysis failed to identify possible solutions to minimise the potential for harm or risk to people. Following us raising our concerns with the management team they committed to reviewing their analysis of incidents with a focus on minimising re-occurrences. Despite our findings people and family members felt Clement Court provided a safe place for them or their relatives to live.

People were supported by staff who responded to medical and clinical needs in a timely way. The provider and management team worked with healthcare partners to ensure people received joined up care and support. All those we spoke with told us they were fully informed about all medical appointments and were supported when they needed to access healthcare partners outside of Clement Court. The provider worked with people and healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services. We saw instances where concerns were identified by staff and these were raised without delay to clinical professions to seek advice and if necessary, treatment. People requiring hospital treatment were supported with a hospital passport. This is a document which provides hospital staff with important information about the person, including their personal preferences as well as their medical needs.

People could not be assured they were safe from avoidable harm. The provider did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

During this inspection we identified 2 incidents where people were put at risk of harm. Staff failed to support people in accordance with the care and support plans and failed to follow fluid thickening guidance. In addition, we saw multiple individuals remained in their beds throughout both days of this inspection. Staff could not provide a reasonable or factually accurate reason why people remained in bed and were not assisted to engage with others in a communal area. This put them at the risk of potential social isolation and healthcare complications resulting from restricted mobility. We raised our concerns with the management team who acted immediately regarding the un-thickened fluids and with the concerns about people being restricted to their beds. In both instances notifications were made to the local authorities adult safeguarding team for their awareness. Some people did not have access or means to call for support when they needed it. One person told us staff did not give them their call bell and they had to shout or bang their table when they needed help. We saw other people where their means to seek support was not readily available, meaning they could not seek assistance when they needed it in a timely way. One person said, “I don’t know how to get help (no call bell was available) and I worry I won’t make it to the toilet in time.”

Despite the provider having necessary procedures in place to support people with their choice in accordance with requirements of the Mental Capacity Act 2025 this was not consistently applied. When people remained in bed this was not always because of them directly choosing to do so but because of the decisions made by those supporting them. We raised our concerns with the provider and the local authority. The provider committed immediately to investigate and address these concerns whilst respecting the choice of those who chose to remain in their rooms. These issues put people at the risk of substandard care and was a breach of legal regulation.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People had individual assessments of risk associated with their personal circumstances. However, these were not always known or followed by staff providing care and support. For example, we saw 2 incidents where staff failed to follow people’s care and support plans or risk assessments. The management team failed to identify the risks to people because of remaining in bed when there was no clinical reason or expressed choice to do so.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, or facilities supported the delivery of safe care.At the last inspection we identified issues with the physical environment. At that inspection the provider was in breach of regulation in relation to the safety of the home. Improvements have been identified, and the provider was no longer in breach of this regulation. However, further improvements were still required. For example, we observed several dead leg pipes where bathroom fixtures had been removed. Dead legs increased the risk of waterborne pathogens including, legionella thereby increasing the health risk to people. Neither the management team nor the maintenance team could identify accurately when these dead legs were created, and these were not identified or rectified as part of their health and safety checks. Doors into areas under alterations were left unlocked. These areas were accessible to people, some of whom were living with dementia, and contained tripping or toppling hazards. A small service lift to the 1st floor had not been risk assessed or secured. This presented a risk of trapping. These concerns put people at the risk of avoidable harm. However, once we identified them to the management team, they took immediate action to remove the potential risks. However, their systems for identifying potential risks in the care environment did not ensure the safe delivery of care.

People were not always supported by staff who were readily available to provide assistance. One person said, “Weekends and holidays are short staffed. They (staff) can take time to get to you when you need it.” Although, the provider stated they had enough qualified, skilled and experienced staff, the deployment and supervision of these staff members failed to ensure people had positive outcomes. Staff and the management team did not always work effectively together to provide safe care that met people’s individual needs.

People were not always supported to do what mattered to them or receive the care and support they wanted. We saw excessive numbers of people remained in bed throughout the day without any good reason. We were told various reasons by staff including “Everyone has a UTI (urinary tract infection),” “we have no hot water,” “we don’t have enough chairs.” However, we could not be assured these explanations were based on fact or included in people’s care plans or risk assessments. The reasons for people remaining in bed for extended periods of time remained unexplained. The management team commenced a review once concerns were raised with them, and they confirmed our concerns where people were not being effectively supported by staff to meet their needs. Our concerns were raised with the local authority’s adult safeguarding team. Staff told us they had not received effective supervision for some time and felt unsupported by the management team. The regional support manager told us they recognised this and owing to recent changes in the management team committed to improve staff members experience of supervision.

People were supported by staff who had been safely recruited.

People could not always be assured they were protected from the risk of communicable illnesses as the provider did not always assess or manage the risk of infection. Improvements were noted in the physical environment since the last inspection and the home had been subject to a programme of redecoration. However, we observed several chairs where the fabric had become torn exposing the foam. This hampered effective cleaning and infection prevention and control practices. Some staff practices were also incompatible with effective infection prevention and control. For example, we saw 1 staff member provide someone with biscuits. The staff member collected a communal side table from elsewhere in the lounge and placed the biscuits directly on the table. They failed to make any attempt to collect a side plate or clean the table. A member of the management team entered and failed to observe or correct this practice. The lack of identification and replacement of worn equipment, the lack of effective practices of staff and oversight of the management team put people at the risks of communicable illnesses.

People could not always be assured they would receive their medicines or prescribed creams as directed. We saw 1 instance where prescribed medicine was left on 1 person’s table for them to take. This medicine was marked as taken with no assurance the person had consumed this medicine. One topical cream had an unreadable label and the recipient of this could not be identified nor could the application instructions be read. Additionally, we saw PRN (as and when required) medicated creams were being given routinely instead of when needed. We asked staff about this, and they did not know when these creams should be effectively used. These issues put people at the risk of having inconsistent support with their prescribed medicines and at risk of their health and wellbeing being impacted. However, people told us they knew what their medicines were, and they had them when they needed them. One person said, “I take tablets for my blood” and another stated they took pain relief when they needed it. Additionally, we did see positives with people’s medicines. Where people received covert medicines, staff knew when and why these were given and the correct processes were followed to ensure their rights were maintained. Staff were trained and assessed as competent to support people.